Holly Hill Mental Health Services

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 36956 Based on review of medical staff bylaws, policies, quality assurance and performance improvement plan, laboratory contract, quality monitoring report, meeting minutes, laboratory specimen collection binders, lab requisition form, personnel file, observation, medical records, physician, mid-level provider, phlebotomist and staff interviews, the hospital’s governing body failed to provide oversight and have systems in place to ensure the hospital’s medical staff adheared to the policy for serum level monitoring of high risk medications and have an effective, on-going data driven quality assessment and performance improvement program that included contracted laboratory services. The findings included: 1. The governing body failed to provide oversight to ensure the medical staff followed the facility policy and manufacturer guidelines for monitoring patient’s serum lithium levels for 1 of 5 patients who was administered lithium (Patient #11). ~cross refer to Governing Body Standard 482.12(a) Tag A0044 2. The governing body failed to have a system in place to ensure the laboratory services provided under contract were evaluated and performed in a safe and effective manner. ~cross refer to Governing Body Standard 482.12(e)(1) Tag A0084 3. The hospital staff failed to analyze and implement quality improvements for contracted laboratory services to improve patient care services and prevent laboratory errors. ~cross refer to QAPI Standard 482.21 Tag A0308 4. The medical staff failed to ensure patient’s serum lithium and valproic acid levels were collected and monitored according to policy, manufacturer guidelines, and/or physician orders for 2 of 5 patients who were administered lithium (Patients #11 and #4) and 1 of 1 patient who was administered Depakote. (Patient #37). ~cross refer to Medical Staff Standard 482.22(b)(1)(2)(3) Tag A0347 5. Hospital staff failed to develop a collaborative, individualized treatment plan that outlined serum lithium level monitoring for 1 of 5 patients that was administered lithium (Patient #11) ~cross refer to Treatment Plan Standard 482.61(c)(1) Tag A1640”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 36956 Based on review of laboratory contract, policy, quality monitoring report, meeting minutes, physician, mid-level provider and staff interviews, the hospital failed to have an effective quality program that included oversight of the contracted laboratory services. The findings included: The hospital staff failed to analyze data and implement quality improvements for contracted laboratory services to improve patient care services and prevent laboratory errors. ~cross refer to QAPI Standard 482.21 Tag A0308”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 36956 Based on review of medical staff bylaws, policies, medical records, laboratory specimen collection binders, lab requisition form, personnel file, observation, physician, mid-level provider and phlebotomist interviews, the hospital’s medical staff failed to provide accountability and oversight to ensure collection and monitoring of serum blood levels for patients on high alert medications according to the hospital’s policy. The findings included: The medical staff failed to ensure patient’s serum lithium and valproic acid levels were collected and monitored according to facility policy, manufacturer guidelines, and/or physician orders for 2 of 5 patients who were administered lithium (Patients #11 and #4) and 1 of 1 patient who was administered Depakote. (Patient #37). ~cross refer to Medical Staff Standard 482.22(b)(1)(2)(3) Tag A0347”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 36956 Based on facility policy review, medical record review, provider and staff interviews, facility staff failed to develop a master treatment plan that was collaborative and described the degree and intensity of the individualized treatment provided to a behavioral health patient. The findings included: Facility staff failed to develop a collaborative, individualized treatment plan that outlined serum lithium level monitoring for 1 of 5 patients that was administered lithium (Patient #11) ~cross refer to Treatment Plan Standard 482.61(c)(1) Tag A1640”

“MEDICAL STAFF CFR(s): 482.12(a) The governing body must: This Standard is not met as evidenced by: 36956 Based on review of medical staff bylaws, policies, medical records, physician and mid-level provider interviews, the Governing Body failed to provide oversight to ensure the medical staff followed the facility policy and manufacturer guidelines for monitoring patient’s serum lithium levels for 1 of 5 patients who was administered lithium (Patient #11). The findings included: Review the “MEDICAL STAFF BYLAWS” effective June 5, 2025 revealed “The purposes of the Medical Staff are: ... to ensure that all patients receiving treatment from the Facility receive uniform quality of care ... to serve as the primary means for accountability to the Board for the quality and appropriateness of the professional performance ... to provide oversight of care, treatment, and services provided by practitioners with privileges, provide for a uniform quality of patient care, treatment and services, and report to and be accountable to the Governing Board. Review of policy titled “High Alert Medications” revised 10/2025 revealed, “STATEMENT OF PURPOSE: ... High alert medications pose a risk to patient safety and must be carefully monitored and controlled. ... The High Alert medications that are applicable to this faciliy include: ... Lithium ... High Alert are medications that require special lab monitoring and have the potential for critical lab results. This facility will follow defined procedures with reporting lab results for these medications. ... PROCEDURE: ... Lithium: The drug will be labeled as high alert in computer systems. New orders and dose adjustments for this drug should be accompanied by an order for lab draws in line with manufacturer guidelines.” Review of the Lithium leaflet provided by Pharmacist #5 revealed “FULL PRESCRIBING INFORMATION ... Obtain serum lithium concentration assay after 3 days, drawn 12 hours after the last oral dose and regularly until patient is stabilized. ... Serum Lithium Monitoring ... Accurate patient evaluation requires both clinical and laboratory analysis. ... In addition to regular monitoring of serum lithium concentrations for patient on maintenance treatment, serum lithium concentrations should be monitored after any change in dosage ...” Review of policy titled “The Role of Nursing in Medication Administration” reviewed 01/2020 revealed, “STATEMENT OF PURPOSE: ... The intent of this policy is to provide needed medication in an efficient, safe manner, and to provide a complete and accurate up-to-date record of all medications a patient receives ... SCOPE OF POLICY: ... Nursing ... Pharmacy ... Physician” Medical record review on 04/10/2026 revealed Patient #11 was admitted under IVC (Involuntary Commitment) petition on 12/28/2025 at 1559 from an outside hospital. The 62-year-old male’s admitting diagnosis was bipolar disorder, unspecified. The “History and Psychiatric Evaluation” revealed Patient #11’s thoughts were “disorganized (disruptive logical thinking) and tangential (disorganized thinking associated with psychosis)” and he had a history of non-medication compliance. Review of the outside hospital documentation revealed a lithium level was collected at the transferring hospital on 12/26/2025 at 0935 and resulted on 12/26/2025 at 1049 (prior to admission) at 0.6 (within normal range). Review of the medication orders for lithium revealed the lithium was ordered to be administered orally as follows: 12/28/2025 300 mg (milligrams) for bipolar disorder one time order; 12/29/2025 300 mg three times a day for mood; 12/30/2025 600 mg three times a day for mood. Review of the MAR (Medication Administration Record) revealed Patient #11 was administered lithium as ordered daily. On 01/06/2026 an order was placed for a Serum Lithium level lab draw which was completed on 01/06/2026 at 0754. On 1/07/2026 at 1630 a nursing note revealed “Lab... called with critical lithium level of 2.4 (range 0.5 to 1.2 normal). NP #1 (Nurse Practitioner) notified. Lithium to be held tonight.” Review of NP #1’s “Psychiatric Progress Note” dated 01/07/2026 at 1452 revealed “Per staff: feels over medicated, compliant, slow to move, confused at times, no acute concerns.... Pt. (Patient) is noted to be slow to respond, forgetful and confused at times, with an unsteady gait during interview (with patient). ... Lithium held due to critical level.” Review of a nursing note dated 01/07/2026 at 1930 revealed “Patient transferred to ER (Emergency Room) due to critical Labs Lithium elevated...” Interview on 04/10/2026 at 0918 with Psychiatrist #2 revealed lithium levels were to be drawn every 3-5 days to ensure levels were stable. Interview revealed the levels sometimes are false positive depending on when lithium was administered and the lab was drawn. Psychiatrist #2 stated, “We don’t always need to treat the level but treat the patient.” He stated, “signs and symptoms of lithium toxicity included confusion and the medication would be stopped.” Interview on 04/10/2026 at 1536 with NP #1 revealed lithium blood draws should be drawn every 3-5 days. NP #1 remembered Patient #11. The patient was transferred from an outside hospital; his lithium level was 0.6 prior to arrival to the hospital and he was on 600 mg of lithium twice a day. NP #1 reviewed the chart and stated on 12/30/2025 the patient was manic and the lithium was increased to 600 mg three times a day. Interview revealed NP #1 was on vacation and returned to work on 01/06/2026 and she ordered the lithium level because he was slow and confused. The patient was due for discharge on 01/07/2026 but she received a call that the patient’s lithium level was 2.4 (toxic). Interview revealed the patient was transferred to an outside hospital due to the critical lithium level and he needed monitoring. Interview revealed NP #1 confirmed she did not know why the lithium level had not been ordered throughout the patient’s admission but stated “it should have been.” Interview on 04/22/2026 at 1455 with the CMO #3 revealed he did not remember the patient’s name but was aware of the patient’s toxic lithium level and the patient should have had a lithium level drawn prior to 01/06/2026. Interview revealed lithium levels are drawn five days after last dose change. Interview on 04/24/2026 at 0910 with CMO #3 revealed the hospital would include the results for patients transferred from other hospitals with known lithium level results into monitoring the levels. In summary, Patient #11 was admitted on 12/28/2025 with a lithium level within normal therapeutic range. The patient was administered lithium 300 mg on 12/28/2025; 300 mg three times a day on 12/29/2025 (900 mg daily total), and lithium 600 mg three times a day from 12/30/2025 through 01/06/2026 (1800 mg daily total for 8 days). Review of the facility’s High Alert Medications policy revealed lithium was identified as a high alert medication and new orders and dose adjustments should be accompanied by lab draws in line with the manufacturer guidelines. Review of the manufacturer guidelines for lithium revealed serum lithium concentrations should be monitored after any change in dosage. There was no monitoring of the patient’s lithium level completed during the 10 days the patient was receiving lithium with increasing dosages. The patient exhibited symptoms of possible lithium toxicity (confusion, slow response, unsteady gait) on 01/06/2026 and a lithium level was obtained that resulted on 01/07/2026 as a critical lab result of 2.4 (range 0.5 to 1.2 normal). The patient was transferred to an acute care emergency department for treatment of lithium toxicity.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 36956 Based on review of quality assurance and performance improvement plan, laboratory contract, policy, quality monitoring report, meeting minutes, physician, mid-level provider and staff interviews, the Governing Body failed to have a system in place to ensure the laboratory services provided under contract were evaluated and performed in a safe and effective manner. The findings included: Review of the “... 2026 Quality Assurance & Performance Improvement (QAPI) revealed “INTRODUCTION ... The successful execution of QAPI program is the result of a foundation of leadership commitment ... ORGANIZATION ...The Governing Body of (hospital) had the ultimate responsibility and authority to establish, maintain and support an effective QAPI program. The Governing Body assures that the necessary structures are established and processes are implemented to assess and continually improve the overall quality and efficiency of patient care. The Governing Body receives and acts upon recommendations regarding quality assessment and improvement activities. ...” Review of the laboratory contract revealed “Reporting ... Standard. All Acute Care and Behavioral Affiliates will have access to the following reports ... Utilization Management, Turn-around-time, Tests Not Performed, Critical Value Summary, Corrected/Amended Results, Agency Reportables ... Our actionable data reports with executive summaries assist in gauging the ‘health’ of an interface and call out the issue, impact and action to be taken to reduce errors and streamline reporting.” Review of “EXHIBIT C...Description of (contract lab service) Interface for Acute Care and Behavioral Health Facilities...Bi-Directional interface developed by (contract lab service) and hosted, maintained by (hospital) which allows (hospital) to electronically transmit test orders to (contract lab service) computer system and for (hospital) computer system to electronically receive transmission of test requests from (contract lab service) System and (contract lab service) computer system to electronically transmit test results to (hospital) System and (hospital) System to electronically receive transmission of such test results from (contract lab service) computer system. ...” Review of policy titled “Performance Improvement Plan” effective 02/2021 revealed “The Performance Improvement Plan identifies that (hospital) continuously seeks ways of providing better care and services. ...The Quality Council ... is responsible for management of performance improvement at (hospital) under the oversight of the Board of Governors. ... PURPOSE ... The performance Improvement Plan is organized to permit participation in quality review activities by all individuals or groups who are affiliated with this facility. ... The purpose of the Performance Improvement Plan is to provide an ongoing process by which (hospital) objectively and systematically monitors and evaluates the quality and appropriateness of patient care, identifies acceptable levels of care, finds and implements opportunities to improve care, and resolves problems and/or submits proposals for the resolution of problems to the Medical Staff Committee, Quality Council and/or the Board of Governors for approval. ... SCOPE OF SERVICES ...Services provided through function that include clinical, medical, nursing and milieu, managerial, administrative and support activities. ... include the following areas: ... Nursing Services ... Psychiatric Services ...Contract Services: ...Medical ...Laboratory ...Support Services: ... pharmacy ...” Review of a “QUALITY MONITORING REPORT LABORATORY RESULTS” included “REPORTING TIME FRAME: 4th Quarter 2025” revealed “PERFORMANCE INDICATORS: ... 1 critical result during Q4 (4th Quarter) ... 1/1 results were reported to House Supervisors ....” Review of an attached report from the contract laboratory service revealed there were 7 serum lithium levels reported that were out of range. The levels were 1.6, 2.0, 2.1, 2.8, 1.6, 1.6, and 1.6 from February 2025 to October 2025. Review of “Quality Council Meeting Minutes” and aggregated data dated January 2025 through December 2025 revealed there was no evidence of analysis or actions taken to improve performance reported for laboratory services. Review of a “QUALITY MONITORING REPORT LABORATORY RESULTS” included “REPORTING TIME FRAME: 1st Quarter 2026” revealed “PERFORMANCE INDICATORS: ...5 critical results during Q1 (1st Quarter) ... 3/5 results were reported to House Supervisors on first attempted phone call ...1/5 results were reported to House Supervisor on second attempted phone call .... 1/5 results were reported to House Supervisor after 3 attempted phone calls 2 Voicemails were left ....” Review of an attached report from the contract laboratory service revealed there were 5 serum lithium levels reported that were out of range. The levels were 1.6, 1.7, 2.4, 2.0, and 1.7 from January 2026 to March 2026. Review of “Quality Council Meeting Minutes” and aggregated data dated January 2026 through March 2026 revealed there was no evidence of analysis or actions taken to improve performance reported for laboratory services. Review of the Medical Staff Executive Meeting Minutes dated 04.16.2026 revealed there was no evidence of analysis or actions taken to improve performance reported for laboratory services. Interview on 04/10/2026 at 0918 with MD#2 revealed there “was an ongoing thing with inconsistency and the laboratory services regarding lab draws.” Interview revealed the doctors talked about laboratory services during quality meetings. Interview revealed the issues had been ongoing for the last 6 - 8 months. Interview on 04/09/20226 at 1126 with NP#1 revealed there was with inconsistency with the laboratory services and required a lot of coordination. Interview revealed “we talked about it.” Interview on 04/22/2026 at 1455 with the CMO revealed all disciplines had to integrate, encourage and monitor to close the laboratory gap for patient safety. Interview on 04/22/2026 at 1548 with the Nurse#2 revealed she received an e-mail from the contract laboratory service with data collected by the contact lab. Interview revealed the results were presented quarterly to the quality committee. Interview revealed with the Nurse#2 reported the results to the quality council which included critical lab values and call time response to the facility to report the critical lab. The nurse reported no corrective actions were taken as a result of her reporting. Interview on 04/22/2026 at 1552 with the Performance Improvement Mgr revealed there was a QAPI (Quality Assurance and Performance Improvement - internal auditing process used to evaluate, ensure and improve quality of activities) dashboard that was presented quarterly to the quality committee. Interview revealed the aggregated data collected and reported did not include laboratory lab values and services.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 36956 Based on review of laboratory contract, policy, quality monitoring report, council meeting minutes, physician, mid-level provider and staff interviews, the hospital staff failed to analyze data and implement quality improvements for contracted laboratory services to improve patient care services and prevent laboratory errors. The findings included: Review of the laboratory contract revealed “Reporting...Standard. All Acute Care and Behavioral Affiliates will have access to the following reports...Utilization Management, Turn-around-time, Tests Not Performed, Critical Value Summary, Corrected/Amended Results, Agency Reportables...Our actionable data reports with executive summaries assist in gauging the ‘health’ of an interface and call out the issue, impact and action to be taken to reduce errors and streamline reporting.” Review of “EXHIBIT C...Description of” Vendor “Interface for Acute Care and Behavioral Health Facilities...Bi-Directional interface developed by” Vendor “and hosted, maintained by” Customer “which allows” Customer to electronically transmit test orders to Vendor computer system and for” Customer “computer system to electronically receive transmission of test requests from” Customer System “and Vendor computer system to electronically transmit test results to”Customer System “and” Customer System “to electronically receive transmission of such test results from Vendor computer system.” Review of policy titled “Performance Improvement Plan” effective 02/2021 revealed “The Performance Improvement Plan identifies that (hospital) continuously seeks ways of providing better care and services. ...The Quality Council ... is responsible for management of performance improvement at (hospital) under the oversight of the Board of Governors. ... PURPOSE ... The performance Improvement Plan is organized to permit participation in quality review activities by all individuals or groups who are affiliated with this facility. ... The purpose of the Performance Improvement Plan is to provide an ongoing process by which (hospital) objectively and systematically monitors and evaluates the quality and appropriateness of patient care, identifies acceptable levels of care, finds and implements opportunities to improve care, and resolves problems and/or submits proposals for the resolution of problems to the Medical Staff Committee, Quality Council and/or the Board of Governors for approval. ... SCOPE OF SERVICES ...Services provided through function that include clinical, medical, nursing and milieu, managerial, administrative and support activities. ... include the following areas: ... Nursing Services ... Psychiatric Services ...Contract Services: ...Medical ...Laboratory ...Support Services: ... pharmacy ...” 1. Review of a “QUALITY MONITORING REPORT LABORATORY RESULTS” included “REPORTING TIME FRAME: 4th Quarter 2025” revealed “PERFORMANCE INDICATORS:...1 critical result during Q4 (4th Quarter)... 1/1 results were reported to House Supervisors....” Review of an attached report from the contract laboratory service revealed there were 7 serum lithium levels reported that were out of range. The levels were 1.6, 2.0, 2.1, 2.8, 1.6, 1.6, and 1.6 from February 2025 to October 2025. Review of “Quality Council Meeting Minutes” and aggregated data dated January 2025 through December 2025 revealed there was no evidence of analysis or actions to improve performance reported for laboratory services. Review of a “QUALITY MONITORING REPORT LABORATORY RESULTS” included “REPORTING TIME FRAME: 1st Quarter 2026” revealed “PERFORMANCE INDICATORS: ...5 critical results during Q1 (1st Quarter)...3/5 results were reported to House Supervisors on first attempted phone call...1/5 results were reported to House Supervisor on second attempted phone call....1/5 results were reported to House Supervisor after 3 attempted phone calls 2 Voicemails were left....” Review of an attached report from the contract laboratory service revealed there were 5 serum lithium levels reported that were out of range. The levels were 1.6, 1.7, 2.4, 2.0, and 1.7 from January 2026 to March 2026. Review of “Quality Council Meeting Minutes” and aggregated data dated January 2026 through March 2026 revealed there was no evidence of analysis or actions to improve performance reported for laboratory services. Review of the Medical Executive Committee Meeting Minutes dated 04/16/2026 revealed the aggregated data collected and reported did not include laboratory lab values and services. Interview on 04/10/2026 at 0918 with MD#2 revealed there “was an ongoing thing with inconsistency and the laboratory services regarding lab draws.” Interview revealed the doctors talked about laboratory services during quality meetings. Interview revealed the issues had been ongoing for the last 6 - 8 months. Interview on 04/09/20226 at 1126 with NP#1 revealed there was inconsistency with the laboratory services and required a lot of coordination. Interview revealed “we talked about it.” Interview on 04/22/2026 at 1455 with the CMO#3 revealed all disciplines had to integrate, encourage and monitor to close the laboratory gap for patient safety. Interview on 04/22/2026 at 1548 with the Nurse #2 revealed she received an e-mail from the contract laboratory service with data collected by the contact lab. Interview revealed the results were presented quarterly to the quality committee. Interview revealed the Nurse #2 reported the results to the quality council which included critical lab values and call time response to the facility to report the critical lab. The nurse reported no corrective actions were taken as a result of her reporting. Interview on 04/22/2026 at 1552 with the Performance Improvement Mgr revealed there was a QAPI (Quality Assurance and Performance Improvement - internal auditing process used to evaluate, ensure and improve quality of activities) dashboard that was presented quarterly to the quality committee. Interview revealed the aggregated data collected and reported did not include laboratory lab values and services. 32003 2. Open medical record review on April 7, 2026 revealed, Patient #4, a 25-year-old-male with a subtherapeutic Lithium level upon IVC admission to the facility on April 6, 2026 at 11:33 PM. The patient had an electronic order and was administered Lithium twice a day. On April 7, 2026 at 8:30 AM, the patient had another electronic order for a Lithium lab collection on the next day at 6:00 AM. On April 8, 2026, the Lithium lab was not collected as ordered by the physician. The lab was collected April 10, 2026 (2 days later). The patient was discharged to home with family on April 11, 2026. The Lithium lab resulted on April 14, 2026 (3 days after discharge). Interview on April 23, 2026 at 11:55 AM with the interim CEO revealed, the facility had no look-behind process to ensure Lithium levels were collected. Interview on 04/22/2026 at 3:52 PM with the Quality Director revealed there was a QAPI (Quality Assurance and Performance Improvement - internal auditing process used to evaluate, ensure and improve quality of activities) dashboard that was presented quarterly to the quality committee. Interview revealed the aggregated data collected and reported did not include laboratory lab values and services. 3. Open medical record review on April 23, 2026 revealed, Patient #37, a 33-year-old female with a therapeutic Lithium level upon IVC admission to facility on April 16, 2026 at 1:57 PM. The patient had an electronic order for the administration of Lithium and Depakote twice a day. On April 22, 2026 at 9:33 PM, the patient had another electronic orders for Lithium and Depakote lab collection on the next day at 6:00 AM. Review revealed the Lithium and Depakote labs were not collected as ordered by the physician. Interview on April 23, 2026 at 11:55 AM with the interim CEO revealed, the facility had no look-behind process to ensure Lithium levels were collected. Interview on 04/22/2026 at 3:52 PM with the Quality Director revealed there was a QAPI (Quality Assurance and Performance Improvement - internal auditing process used to evaluate, ensure and improve quality of activities) dashboard that was presented quarterly to the quality committee. Interview revealed the aggregated data collected and reported did not include laboratory lab values and services.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 36956 Based on review of medical staff bylaws, policies, medical records, laboratory specimen collection binders, lab requisition form, personnel file, observation, physician, mid-level provider and phlebotomist interviews, the medical staff failed to ensure patient’s serum lithium and valproic acid levels were collected and monitored according to policy and manufacturer guidelines, and/or physician orders for 2 of 5 patients who were administered lithium (Patients #11 and #4) and 1 of 1 patient who was administered Depakote. (Patient #37). The findings included: Review the “MEDICAL STAFF BYLAWS” effective June 05, 2025 revealed “The purposes of the Medical Staff are: ... to ensure that all patients receiving treatment from the Facility receive uniform quality of care ... to serve as the primary means for accountability to the Board for the quality and appropriateness of the professional performance ... to provide oversight of care, treatment, and services provided by practitioners with privileges, provide for a uniform quality of patient care, treatment and services, and report to and be accountable to the Governing Board. ...” Review of policy titled “High Alert Medications” revised 10/2025 revealed, “STATEMENT OF PURPOSE:...High alert medications pose a risk to patient safety and must be carefully monitored and controlled .... The High Alert medications that are applicable to this faciliy include: ... Lithium ... High Alert are medications that require special lab monitoring and have the potential for critical lab results. This facility will follow defined procedures with reporting lab results for these medications. ... PROCEDURE: ... Lithium: The drug will be labeled as high alert in computer systems. New orders and dose adjustments for this drug should be accompanied by an order for lab draws in line with manufacturer guidelines.” Review of the Lithium leaflet (Manufacturer Recommendations) provided by Pharmacist #5 revealed “FULL PRESCRIBING INFORMATION ... Obtain serum lithium concentration assay after 3 days, drawn 12 hours after the last oral dose and regularly until patient is stabilized .... Serum Lithium Monitoring ... Accurate patient evaluation requires both clinical and laboratory analysis .... In addition to regular monitoring of serum lithium concentrations for patient on maintenance treatment, serum lithium concentrations should be monitored after any change in dosage ...” Review of policy titled “The Role of Nursing in Medication Administration” reviewed 01/2020 revealed “STATEMENT OF PURPOSE: ... The intent of this policy is to provide needed medication in an efficient, safe manner, and to provide a complete and accurate up-to-date record of all medications a patient receives ... SCOPE OF POLICY: ... Nursing ... Pharmacy ... Physician” 1. Medical record review on 04/10/2026 revealed Patient #11 was admitted under IVC (Involuntary Commitment) petition on 12/28/2025 at 1559 from an outside hospital. The 63-year-old male’s admitting diagnosis was bipolar disorder, unspecified. The “History and Psychiatric Evaluation” revealed Patient #11’s thoughts were “disorganized (disruptive logical thinking) and tangential (disorganized thinking associated with psychosis)” and he had a history of non-medication compliance. Review of the outside hospital documentation revealed a lithium level was collected at the transferring hospital on 12/26/2025 at 0935 (prior to admission) and resulted on 12/26//2025 at 1049 at 0.6 (within normal range). Review of the medication orders for lithium (mood stabilizer that is used to treat the manic episodes of bipolar disorder) revealed the lithium was ordered to be administered orally as follows: 12/28/2025 300 mg (milligrams) for bipolar disorder one time order; 12/29/2025 300 mg three times a day for mood; 12/30/2025 600 mg three times a day for mood. Review of the MAR (Medication Administration Record) revealed Patient #11 was administered lithium as ordered daily. On 01/06/2026 an order was placed for a Serum Lithium level lab draw which was completed on 01/06/2026 at 0754. On 1/07/2026 at 1630 a nursing note revealed “Lab... called with critical lithium level of 2.4 (range 0.5 to 1.2 normal). NP #1 (Nurse Practitioner) notified. Lithium to be held tonight.” Review of NP #1’s “Psychiatric Progress Note” dated 01/07/2026 at 1452 revealed “Per staff: feels over medicated, compliant, slow to move, confused at times, no acute concerns .... Pt. (Patient) is noted to be slow to respond, forgetful and confused at times, with an unsteady gait during interview (with patient). ... Lithium held due to critical level.” Review of a nursing note dated 01/07/2026 at 1930 revealed “Patient transferred to ER (Emergency Room) due to critical Labs Lithium elevated ...” Interview on 04/10/2026 at 0918 with Psychiatrist #2 revealed lithium levels were to be drawn every 3-5 days to ensure levels were stable. Interview revealed the levels sometimes are false positive depending on when lithium was administered and the lab was drawn. Psychiatrist stated, “we don’t always need to treat the level but treat the patient.” He stated, “signs and symptoms of lithium toxicity included confusion and the medication would be stopped.” Interview on 04/10/2026 at 1536 with NP #1 revealed lithium blood draws should be drawn every 3-5 days. NP #1 remembered Patient #11. The patient was transferred from an outside hospital; his lithium level was 0.6 prior to arrival to the hospital and he was on 600 mg of lithium twice a day. NP #1 reviewed the chart and stated on 12/30/2025 the patient was manic and the lithium was increased to 600 mg three times a day. Interview revealed NP #1 was on vacation and returned to work on 01/06/2026 and she ordered the lithium level because he was slow and confused. The patient was due for discharge on 01/07/2026 but she received a call that the patient’s lithium level was 2.4 (toxic). Interview revealed the patient was transferred to an outside hospital due to the critical lithium level and he needed monitoring, including cardiac, EKG and electrolytes. Interview revealed NP #1 confirmed she did not know why the lithium level had not been ordered throughout the patient’s admission but stated “it should have been.” Interview on 04/22/2026 at 1455 with the CMO #3 revealed he did not remember the patient’s name but was aware of the patient’s toxic lithium level and the patient should have had a lithium level drawn prior to 01/06/2026. Interview revealed lithium levels are drawn five days after last dose change. Interview on 04/24/2026 at 0910 with the CMO #3 revealed the hospital would include the results for patients transferred from other hospitals with known lithium level results into monitoring the levels. In summary, Patient #11 was admitted on 12/28/2025 with a lithium level within normal therapeutic range. The patient was administered lithium 300 mg on 12/28/2025; 300 mg three times a day on 12/29/2025 (900 mg daily total), and lithium 600 mg three times a day from 12/30/2025 through 01/06/2026 (1800 mg daily total for 8 days). Review of the facility’s High Alert Medications policy revealed lithium was identified as a high alert medication and new orders and dose adjustments should be accompanied by lab draws in line with the manufacturer guidelines. Review of the manufacturer guidelines for lithium revealed serum lithium concentrations should be monitored after any change in dosage. There was no monitoring of the patient’s lithium level completed during the 10 days the patient was receiving lithium with increasing dosages. The patient exhibited symptoms of possible lithium toxicity (confusion, slow response, unsteady gait) on 01/06/2026 and a lithium level was obtained that resulted on 01/07/2026 as a critical lab result of 2.4 (range 0.5 to 1.2 normal). The patient was transferred to an acute care emergency department for treatment of lithium toxicity. 32003 2. Open medical record review on April 7, 2026 revealed, Patient #4, a 25-year-old-male was an IVC admission to the facility on April 6, 2026 at 11:33 PM for psychosis unspecified. Upon admission, the patient was housed in an [adult male unit], the Lithium level was reported as 0.1 millimoles per liter (mmol/L), subtherapeutic, from the transferring facility and the patient had a medication history of Lithium carbonate 600 milligrams (mg) orally twice a day for mood. On April 7, 2026 at 8:30 AM, the patient had an electronic order for a Lithium lab collection on the next day at 6:00 AM. On April 8, 2026 at 2:00 AM, the patient was transferred to an [acute adult male unit] for behaviors. On April 8, 2026 at 6:00 AM the Lithium lab was not collected as ordered by the physician. On April 11, 2026, the patient was discharged to home with family. Discharge medications revealed continuation of Lithium carbonate 600 mg orally twice a day. Review revealed, the facility discharged the patient to home without knowledge of the Lithium level. Review on April 23, 2026 of the laboratory specimen collection binder for [adult male unit] revealed on April 8, 2026, Patient #4 transferred and there was no documentation that the routine laboratory specimens were collected. Additional review revealed that the routine laboratory specimens were collected on April 10, 2026 (2 days later). Review on April 23, 2026 of the laboratory requisition from [vendor] revealed, [specimen number] was collected/received April 10, 2026 at 12:00 AM, entered April 12, 2026 at 8:18 PM and reported April 14, 2026 6:35 AM as 0.8 mmol/L, therapeutic (3 days after discharge). On-boarding file review on April 24, 2026 revealed that the [vendor] assigned three phlebotomists (two full-time and one part-time) to the facility wherein each file failed to contain a current venipuncture skill assessment or attestation. Interview on April 21, 2026 at 2:08 PM with the Chief Medical Officer/Psychiatrist revealed for Patient #4, the Lithium dosage at the facility was the same as the home dosage, as the psychiatrist was not too overly concerned about the Lithium level from the transferring facility; however, the psychiatrist did acknowledge that the Lithium level should have been collected and resulted before the patient discharged. Interview on April 23, 2025 at 11:27 AM with the interim CNO revealed going forward, the Pharmacist will also be responsible for reviewing laboratory results and communication with the provider if a medication should be held. Interview on April 23, 2026 at 11:55 AM with the interim CEO revealed, the facility had no look-behind process to ensure Lithium levels were collected. Interview on April 23, 2026 at 3:15 PM with Nurse #1 revealed, the laboratory specimen collection book was a source of information for patient lab collection, wherein instances that increased the potential for missed labs were: no communication between staff and the phlebotomist when a patient transferred to another unit; patient acuity on the unit and inadequate information exchanged during the nurse-to-nurse report. Interview on April 24, 2026 at 11:05 AM with [vendor] Phlebotomist #2 revealed on April 12, 2026, Phlebotomist #1 (same vendor), added a lithium level to the laboratory specimen collected on April 10, 2026 for Patient #4. The lithium level should not have been added-on because medication labs such as lithium were collected/bagged separately, considered a “same day” lab that measured the amount of medication in the blood system at the time of collection. 3. Open medical record review on April 23, 2026 revealed, Patient #37, a 33-year-old female was an IVC admission to facility on April 16, 2026 at 1:57 PM for behavioral changes due to decreased dosage of psychiatric medication. Upon admission, the patient was housed in [acute adult female unit], the Lithium level was reported as 0.55 milliequivalents per liter (mEq/L), therapeutic, from the transferring facility and the patient had a medication history of Lithium 300 milligrams (mg) orally twice a day and Depakote (valproic acid/divalproex sodium) both for Bipolar disorder. On April 22, 2026 at 9:33 PM, the patient had an electronic orders for Lithium and Depakote lab collection on the next day at 6:00 AM. Review revealed the Lithium and Depakote labs were not collected as ordered by the physician. Review on April 23, 2026 of the laboratory specimen collection binder from [acute adult female unit] revealed, the laboratory collection form was missing for April 23, 2026. Interview on April 23, 2026 at 5:57 PM with the Performance Improvement Manager revealed, [vendor] phlebotomist could not find the laboratory collection binder for [acute adult female unit] and the phlebotomist failed to notify anyone (nurse, etc.,) of the problem. Interview revealed the facility staff contacted [vendor] and they were unable to send a phlebotomist to the facility. Unit tours on April 23, 2026 from 6:19 PM till 6:45 PM (26-minutes) revealed, the facility staff failed to ensure labs were collected for 1 of 9 inpatient unit [acute female adult unit] located at the main campus. Interview on April 23, 2026 at 6:37 PM with mental health technician revealed she had five patients to collect labs for on [acute adult female unit]. Interview on April 24, 2026 at 9:06 AM with [vendor] Phlebotomist #2 revealed, during the weekday, there were two phlebotomists at the facility. One phlebotomist collected labs at: Children’s hospital (4 units), South Building (2 units) and one unit at the Main Campus. The second phlebotomists collected labs for the remaining eight units at the Main Campus. Interview revealed, labs were not collected on April 23, 2026 for the [acute adult female unit] because the phlebotomist could not find the lab specimen collection binder. The binder should have been in the medication room. The medication room was looked over two times; all the drawers and all the cabinets were also searched but no one could find the binder. Before leaving the unit, staff were informed to call the phlebotomist once they found the binder but no call was received from the facility staff. Interview revealed, the phlebotomist was made aware that no labs were collected for an unit in the main campus during a telephone discussion with the supervising and Regional Managers from [vendor]. The corrective actions for the missed labs included for the [vendor] phlebotomists to call the facility’s supervisor at xxx-xxx-2003 when the laboratory specimen collection binder could not be located and/or the inability to collect patient labs. Additionally, in instances when a patient transferred to another unit, the facility staff should provide the phlebotomist with the new patient location. Also, phlebotomists were required to look 2-4 days behind to ensure labs were collected and that there were no duplicate lab draws, unless it was a STAT lab. Interview revealed, the facility staff implemented a new process to ensure lab collection. Interview on April 24, 2026 at 11:12 AM with the Performance Improvement Manager revealed, the facility did not keep a copy of the phlebotomists personnel file on-site and they were dependent on [vendor] to ensure the phlebotomists demonstrated or attested to venipuncture competency.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 36956 Based on facility policy review, medical record review and provider and staff interviews, facility staff failed to develop a collaborative, individualized treatment plan that outlined serum lithium level monitoring for 1 of 5 patients that was administered lithium (Patient #11) The findings included: Review of the policy titled “interdisciplinary Patient-Centered Care Planning ...” effective 03/2025 revealed POLICY: ... It is the policy ... to provide therapeutic services based upon a patient centered individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient’s assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patient’s progress and determine if any modifications are needed. ... Each discipline completing their individual assessments will begin to identify the patient’s problems to be treated and the focus of their treatment interventions which will be included in the MTP (Master Treatment Plan).” Review of policy titled “High Alert Medications” revised 10/2025 revealed, “STATEMENT OF PURPOSE:...High alert medications pose a risk to patient safety and must be carefully monitored and controlled .... The High Alert medications that are applicable to this facility include: ... Lithium ... High Alert are medications that require special lab monitoring and have the potential for critical lab results. This facility will follow defined procedures with reporting lab results for these medications. ... PROCEDURE: ... Lithium: The drug will be labeled as high alert in computer systems. New orders and dose adjustments for this drug should be accompanied by an order for lab draws in line with manufacturer guidelines.” Review of the Lithium leaflet (Manufacturer Recommendations) provided by Pharmacist #5 revealed “FULL PRESCRIBING INFORMATION ... Obtain serum lithium concentration assay after 3 days, drawn 12 hours after the last oral dose and regularly until patient is stabilized .... Serum Lithium Monitoring ... Accurate patient evaluation requires both clinical and laboratory analysis .... In addition to regular monitoring of serum lithium concentrations for patient on maintenance treatment, serum lithium concentrations should be monitored after any change in dosage ...” Review of policy titled “The Role of Nursing in Medication Administration” reviewed 01/2020 revealed “STATEMENT OF PURPOSE: ... The intent of this policy is to provide needed medication in an efficient, safe manner, and to provide a complete and accurate up-to-date record of all medications a patient receives ... SCOPE OF POLICY: ... Nursing ... Pharmacy ... Physician” Medical record review on 04/10/2026 revealed Patient #11 was admitted under IVC (Involuntary Commitment) petition on 12/28/2025 at 1559 from an outside hospital. The 63-year-old male’s admitting diagnosis was bipolar disorder, unspecified. The patient was administered lithium 300 mg on 12/28/2025; 300 mg three times a day on 12/29/2025 (900 mg daily total), and lithium 600 mg three times a day from 12/30/2025 through 01/06/2026 (1800 mg daily total for 8 days). There was no monitoring of the patient’s lithium level completed during the 10 days the patient was receiving lithium with increasing dosages. Review of the Master Treatment Plan and Individual Treatment Plan Problem Sheet dated 12/29/2025 revealed patient #11’s Problem included medication non-compliance with a long term goal (patient #11) “will demonstrate medication compliance for 3-5 consecutive days” (target date 01/29/25 -sic -26) ... Short-Term Goal: ... Taking the prescribed medication at least 5 out of 7 days this week (target date 01/5/2025 sic - 26), ... Physician will assess effectiveness of medication in reducing dysregulated behaviors Physician will assess (patient #11) changes in behavior to progress towards being ready for discharge. ...” Review of “Master Treatment Plan Review” dated 01/02/2026 at 1350 revealed “problem non-mod (sic - med) ... At baseline ...” and there were no any revisions or updates. Review revealed there were no other treatment plan revisions noted and no discussion related to serum lithium draw during the interdisciplinary team meeting dated 01/02/2026 at 1350. Interview on 04/10/2026 at 1536 with NP #1 revealed lithium blood draws should be drawn every 3-5 days. NP #1 remembered Patient #11. The patient was transferred from an outside hospital; his lithium level was 0.6 prior to arrival to the hospital and he was on 600 mg of lithium twice a day. NP #1 reviewed the chart and stated on 12/30/2025 the patient was manic and the lithium was increased to 600 mg three times a day. Interview revealed NP #1 was on vacation and returned to work on 01/06/2026 and she ordered the lithium level because he was slow and confused. The patient was due for discharge on 01/07/2026 but she received a call that the patient’s lithium level was 2.4 (toxic). Interview revealed the patient was transferred to an outside hospital due to the critical lithium level and he needed monitoring, including cardiac, EKG and electrolytes. Interview revealed NP #1 confirmed she did not know why the lithium level had not been ordered throughout the patient’s admission but stated “it should have been.” Interview on 04/21/2026 at 1605 with Pharmacist #5 revealed lithium lab draws were left up to the provider’s discrepancy. Interview on 04/22/2026 at 0940 with Pharmacist #5 revealed prior dose of lithium needed to be stopped for accurate levels to determine toxicity. The night shift nurse should hold the dose. The nurse should check the MAR (Medication Administration Record) to see if there was an order for lithium levels and would hold the medication. Interview on 04/22/2026 at 1455 with the CMO#3 revealed all disciplines had to integrate, encourage and monitor to close the laboratory gap for patient safety. In summary, review of the facility’s High Alert Medications policy revealed lithium was identified as a high alert medication and new orders and dose adjustments should be accompanied by lab draws in line with the manufacturer guidelines. Review of the manufacturer guidelines for lithium revealed serum lithium concentrations should be monitored after any change in dosage. There was no monitoring of the patient’s lithium level completed during the 10 days the patient was receiving lithium with increasing dosages. The patient exhibited symptoms of possible lithium toxicity (confusion, slow response, unsteady gait) on 01/06/2026 and a lithium level was obtained that resulted on 01/07/2026 as a critical lab result of 2.4 (range 0.5 to 1.2 normal). The patient was transferred to an acute care emergency department for treatment of lithium toxicity. Review of Patient #11’s Master Treatment Plan failed to include monitoring of the patient’s serum lithium levels to prevent toxicity.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 36956 Based on policy and procedure review, Medical Staff Bylaws, Rules and Regulations, video camera review, medical record review and staff interviews, the facility’s governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient’s rights to provide a safe environment that was free from elopement for behavioral health patients and failed to have an organized nursing service and adequate staff to supervise and meet patient care and safety needs. The findings included: 1. The facility staff failed to provide care in a safe setting by failing to assess and monitor behavioral health patients to prevent the elopement of two patients from two different campuses of the hospital. (Patients #21 and #11 ~cross refer to 482.13(c)(3) Patients’ Rights - right to receive care in a safe setting : tag A0144 2. Facility nursing staff failed to ensure supervision and assessment was provided by a RN (Registered Nurse) for behavioral health patients to prevent the elopement of two patients from two different campuses of the hospital. (Patients #21 and #11) ~cross refer to 483.23(b)(3) Nursing Services - RN Supervision of Nursing Care: tag A0395 3. Facility staff failed to monitor and supervise care to prevent behavioral health patients elopements. (Patients #21 and #11) ~cross refer to 482.62(d)(2) Special Staff Requirements for Psychiatric Hospitals: tag 1704”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36956 Based on policy review, medical record reviews, video footage review, observation, and staff interviews, the facility failed to protect and promote patients’ rights by neglecting to ensure a safe environment for the delivery of care to behavioral health patients to prevent elopement. The findings included: The facility failed to provide care in a safe setting by failing to assess and monitor behavioral health patients to prevent the elopement of two patients from two different campuses of the hospital. (Patients #21 and #11) ~cross refer to 482.13(c)(2) Patients’ Rights - Care in a Safe Setting: tag A0144”

“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: 36956 Based on policy review, medical record reviews, video footage review, observation and staff interviews, the facility’s nursing staff failed to have an effective nursing service providing oversight of day-to-day operations by failing to ensure systems were in place to ensure nursing supervision and assessment was provided to prevent elopement of behavioral health patients. The findings included: Hospital staff failed to ensure nursing supervision and assessment was provided by a RN (Registered Nurse) for behavioral health patients to prevent elopement of two patients from two different campuses of the facility. (Patients #21 and #11) ~cross refer to 483.23(b)(3) Nursing Services - RN Supervision of Nursing Care: tag A0395”

“Special Staff Requirements CFR(s): Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This Condition is not met as evidenced by: 36956 Based on policy review, medical record reviews, video footage review, observation, and staff interviews, the facility failed to provide adequate professional and supportive staff to supervise, monitor, expedite care and prevent behavioral health patients elopements. Findings included: Facility staff failed to monitor and supervise care to prevent behavioral health patients elopements. (Patients #21 and #11) ~cross refer to 482.62(d)(2) Special Staff Requirements for Psychiatric Hospitals: tag 1704”

“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: 36956 Based on policy review, medical record reviews, video footage review, observation, and staff interviews, the facility failed to provide care in a safe setting by failing to assess and monitor behavioral health patients to prevent the elopement of two patients from two different campuses of the facility. (Patients #21 and #11) The findings included: Review of a facility policy titled “Elopement Prevention and Precaution” last reviewed 12/2025 revealed, “POLICY ...It is the policy of (named facility) to provide a safe, therapeutic environment of care including the prevention of patient elopement from the facility or activities on or off grounds ....To provide a plan for Prevention of Elopement from the facility by identifying early warning signs of elopement risk, monitoring the patient with a suspected potential for an attempt to elope, and implementing intervention steps to minimize the risk of elopement ....To provide a Response and Notification Plan in the event of an elopement incident including the process for calling ‘Code Walker’ in order to return the patient to the facility ....DEFINITIONS ...Elopement - The Patient has left/run away from the facility premises/property, and whereabouts are unknown for any period of time ....Found in Unauthorized area- In unsupervised area on property without staff knowledge....ACTION STEPS ...EARLY IDENTIFICATION...Risk for elopement is assessed for all patients upon intake and admission via Intake Assessment and the High Risk Communication Tool ....The below information is collected at the time of assessment to help determine and identify patient specific risk factors ....Prior history of elopement from previous treatment facilities ...checking door, loitering near doorways, and/or pacing in front of exit doors ...INTERVENTION: ...Unit Staff ...Stagger 15 minute Observation Rounds to prevent predictable rounding checks and maintain visibility of patient throughout shift as much as possible” 1. Medical record review on 02/27/2026 revealed on 02/26/2026 at 1125 patient #21 arrived at the facility admissions area on campus A (main campus) and was placed in the waiting area/lobby. The 36 year old male was involuntarily committed with Q (every) 15 minutes observation checks. Review of the “ADMISSIONS PRECAUTIONS CHECK SHEET” by PST (Patient Support Technician) #4 dated 02/26/2026 at 1125 revealed from 1130 to 1345 patient #21 was sitting in the lobby. At 1400 the patient was sitting in the hallway. Review revealed from 1415 to 1430 the patient was sitting in the lobby and from 1445 to 1545 the check sheet revealed the patient was sitting in the hallway. Review revealed there was not an elopement risk assessment documented in patient #21’s medical record on 02/26/2026 after arrival and prior to elopement. Review revealed patient #21 was transferred from another facility. Review of the transferring facility’s documentation revealed patient #21 was admitted to the transferring facility on 02/23/2026 with a diagnosis of “Acute psychosis with suicidal ideation.” Review of the “Psychosocial Flowsheet” dated 02/25/2026 from the transferring facility revealed “Precautions ...Elopement ...02/25/26/1022”. Review of facility video footage on 02/27/2026 at 1333 for patient #21 revealed on 02/26/2026 at 1133 the patient entered the waiting area from the intake/admission foyer. The patient wore paper scrubs and six other patients were in the waiting room. There were two PSTs (Patient Support Technician) PST #4 and PST #5 located in the receptionist area with full view of the lobby. At 1137 the patient was pacing in the waiting room, and at 1142 the patient approached and lingered at the door that lead into the intake admission foyer. At 1201 Clinician #6 (Social Worker) opened the waiting room door, motioned to patient #21 to exit the room into the hallway after a verbal altercation with another patient. PST #5 escorted the patient to consult room #2 and the patient was provided a meal tray that included a bag of potato chips. The patient woke up from a nap, exited the consult room, entered into the hallway, proceeded to the exit door at the end of the hallway. The patient pushed at the exit door metal plate that enclosed the key lock for the exit door. At 1214 the patient attempted to open the exit door and at 1216 he hid behind the wall next to the exit door. He paced the hallway at 1217 and checked all the door handles on the hallway. At 1222 the patient was biting at the exit door key lock panel. At 1223 the patient was back in the consult room, stood in the doorway and peeped into the hallway. At 1224 the patient was at the exit door and pulled at the door handle. At 1343 the patient positioned his mouth under a hand sanitizer dispenser, pressed the dispenser button and obtained contents from the dispenser into his mouth. The patient proceeded to the exit door key lock, placed his mouth over the key lock and expelled the contents from mouth onto the key lock. The patient repeated this behavior two more times. At 1403 the patient placed what appeared to be a portion/piece of a potato chip bag between the exit door and the door frame. He then pushed his back against the exit door but the door did not open. At 1409 PST #5 placed a Smart Serve tracking device (an electronic wrist band used by staff for patient observation and location during 15 minute checks) onto the patient’s left wrist (2 hours and 44 minutes after the patient arrived). Patient #21 walked to the exit door and rubbed the tracking device against the exit door frame. At 1416 he detached the hand sanitizer dispenser from the wall, placed the dispenser into his scrub pants and removed the screw from the wall where the dispenser was once mounted. At 1429 the patient had something in his hand and picked at the exit door key lock. Between 1431 to 1435 the patient tampered with the key lock and at times removed screws from his mouth to assist in the tampering. At 1441 the bottom of the key lock plate was bent upward, he pushed and placed his finger behind the plate, the exit door was unlocked and patient exited the door (3 hours and 16 minutes after arrival). There was not any staff on the hallway. At 1501 staff appeared on the hall, staff searched the rooms and at 1542 (one hour and one minute post elopement), a code walker was called. Interview on 02/27/2026 at 1507 with the CEO (Chief Executive Officer) #7 revealed patient #21 had not been located. Interview on 02/27/2026 at 0937 with the Director #3 revealed staffing for the intake area consisted of 2 PSTs, at least 1 RN (Registered Nurse) and Clinicians. Interview revealed the PSTs checked patients into the area and performed observations. The RN assessed the patients, triaged walk-in patients and was the only staff that obtained orders. The Clinicians had master’s degrees; some were licensed and some were not. Clinicians performed administrative duties for insurance, referrals, met with and assessed patients to determine the patient’s behaviors. Interview revealed patient #21 was Involuntarily Committed ( IVC’d), he had verbal altercations with several patients and was moved to the admissions hallway. The Director stated, “once moved to the admissions hall he should have been within line of sight ....PST staff usually determine when patients are separated. PST #4 performed observation last night and I am not sure if the RN was made aware the patient was moved from the waiting room to the hallway.” 2. Observation revealed I saw an unknown female standing across the street from campus A on 02/25/2026 at 0815. Observation revealed facility staff COO (Chief Operations Officer) #10 and CEO #7 were talking to an un-named female located across the street from campus A. The staff was talking to the female and she was yelling at staff. The transport van arrived and staff from the van walked toward the front of the building. The female walked away from the staff to the corner and around the side of the building out of view. The staff left the area; the transport driver entered the van and drove around the building. Medical record review on 02/27/2026 revealed patient #11 voluntarily arrived at campus A on 02/24/2026 at 2341 and was admitted to campus B ( South campus). Review of “ObservSMART ...BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET” dated 02/25/2026 revealed patient #11 was located at the nursing station at 0709 on campus B with Q 15 minute checks. Documentation from 0724 to 0754 revealed “other” was the patient’s location and from 0739 to 0754 the patient’s behavior was “Crying/Tearful.” Video review on 02/26/2026 at 1316 revealed on 02/25/2026 at 0735 patient #11 was on campus B and located in the 3 South West unit telephone room and she stood at the telephone room window and was looking towards the nursing station. BRS (Behavioral Response Specialist) #9 was standing on the outer side of the nursing station in the milieu. At 0735:44 patient #11 exited the telephone room, approached the nursing station and stood behind the BRS #9. The BRS’s #9 back was toward patient #11. At 0736 the BRS #9 turned toward the unit hallway and reached into her left scrub pocket. The BRS’s #9 badge dropped to the floor and the staff member proceeded walking down the hallway. Patient #11 reached down and picked up the BRS’s #9 badge. The patient walked onto the unit hallway and at 0736:33 the patient was out of camera view. At 0743:40 (7 minutes later) the patient was seen exiting the buildings’ west side exit door to the outside. At 0743:46 the patient was seen walking outside the gym towards the front of the building. No additional video footage available. Interview on 02/25/2026 at 0905 with the CEO #7 revealed the female located across the street from campus A was identified as patient #11. The patient was admitted voluntarily to campus B and post elopement patient #11 was IVC’d to campus A per the doctor’s orders. Interview on 02/25/2026 at 1336 with BRS #9 revealed she worked at campus B since June of 2025. Interview revealed on 02/25/2026 patient #11 “had been yelling, screaming and cursing at staff all morning.” Interview revealed the patient “was on the phone” and said, “we were holding her against her will.” She revealed the phone is near the nursing station. The BRS #9 stated, “I was in and out of the patient’s rooms performing environmental rounds. I thought the patient got my badge when I gathered linen out of the rooms and my badge must have fallen then.” She stated “even though I was doing environmental rounds I was able to still hear her. At some point I did not hear her and I asked a peer if she saw the patient.” She said, ‘the last time I saw her she was on the phone.’ “I looked for her in the phone room, her bedroom, the shower and she was not there. I immediately reached across the nursing station desk, grabbed the walkie talkie and called a code walker. Everyone was looking for her.” The BRS #9 stated “I was told to place the badge in my pocket prior to the elopement but staff always tucked the badges inside our scrub top.” She stated, “I usually wear a zip up jacket and today I wore a hoodie and the badge was clipped to the outside of my scrubs.” Interview revealed “I was given my badge back by leadership.” Interview on 02/25/2026 at 1626 with the CEO #7 revealed patient #11 was located on Campus B third floor prior to the elopement. The CEO #7 revealed she arrived for work on 02/25/2026 around 0740 onto campus A. The CEO #7was approached outside campus A by the COO #10 who reported a lady outside campus A ‘was asking for her belongings.’ The COO #10 thought the lady had been discharged. He checked the computer and realized she was a current patient (patient #11) at campus B. The CEO #7 stated “I instructed staff to please get the provider on the phone. The provider gave orders to IVC her until provider could assess the patient. Transport staff placed her into the van. They used CPI (Crisis Prevention Intervention) to place her into the van and she taken to campus A to 2NB (2 North B - Acute co-ed unit).” Interview revealed “staff are told to always wear badges out of sight.” The CEO #7 stated, “keys were being provided to all staff today to exit all outside doors.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 36956 Tag 0395 - Nursing Based on policy review, medical record reviews, video footage review, observation and staff interviews, the facility nursing staff failed to ensure nursing supervision and assessment was provided by a RN (Registered Nurse) for behavioral health patients to prevent elopement of two patients from two different campuses of the facility. (Patients #21 and #11) The findings included: Review of facility policy titled “Elopement Prevention and Precaution” last reviewed 12/2025 revealed POLICY...It is the policy of (named facility)to provide a safe, therapeutic environment of care including the prevention of patient elopement from the facility or activities on or off grounds ....To provide a plan for Prevention of Elopement from the facility by identifying early warning signs of elopement risk, monitoring the patient with a suspected potential for an attempt to elope, and implementing intervention steps to minimize the risk of elopement ....To provide a Response and Notification Plan in the event of an elopement incident including the process for calling ‘Code Walker’ in order to return the patient to the facility ....DEFINITIONS ...Elopement - The Patient has left/run away from the facility premises/property, and whereabouts are unknown for any period of time ....Found in Unauthorized area- In unsupervised area on property without staff knowledge ....ACTION STEPS ...EARLY IDENTIFICATION ...Risk for elopement is assessed for all patients upon intake and admission via Intake Assessment and the High Risk Communication Tool ....The below information is collected at the time of assessment to help determine and identify patient specific risk factors ....Prior history of elopement from previous treatment facilities ...checking door, loitering near doorways, and/or pacing in front of exit doors ...INTERVENTION: ...Unit Staff ...Stagger 15 minute Observation Rounds to prevent predictable rounding checks and maintain visibility of patient throughout shift as much as possible” The findings included: 1. Medical record review on 02/27/2026 revealed on 02/26/2026 at 1125 patient #21 arrived at the facility admissions area on campus A (main campus) and was placed in the waiting area/lobby. The 36 year old male was Involuntary committed with Q (every) 15 minutes observation checks. Review of the “ADMISSIONS PRECAUTIONS CHECK SHEET” by PST (Patient Support Technician) #1 dated 02/26/2026 at 1125 revealed from 1130 to 1345 patient #21 was sitting in the lobby. At 1400 the patient was sitting in the hallway. Review revealed from 1415 to 1430 the patient was sitting in the lobby and from 1445 to 1545 the check sheet revealed the patient was sitting in the hallway. Review of the medical record revealed patient #21 was at the facility from 1125 until 1441 and there was not a notation by a RN regarding the patients’ needs and goals. Review revealed patient #21 was transferred from another facility. Review of transferring facility’s documentation revealed patient #21 was admitted to the transferring facility on 02/23/2026 with a diagnosis of “Acute psychosis with suicidal ideation.” Review of the “Psychosocial Flowsheet” dated 02/25/2026 from the transferring facility revealed Precautions...Elopement...02/25/26 1022”. Review of facility video footage on 02/27/2026 at 1333 for patient #21 revealed on 02/26/2026 at 1133 the patient entered the waiting area from the intake/admission foyer. The patient wore paper scrubs and six other patients were in the waiting room. There were two PSTs (Patient Support Technician) PST #4 and PST #5 located in the receptionist area with full view of the lobby. At 1137 the patient was pacing in the waiting room and at 1142 the patient approached and lingered at the door that lead into the intake admission foyer. At 1201 Clinician #6 (Social Worker)_ opened the waiting room door, motioned to patient to exit the room into the hallway after a verbal altercation with another patient. PST #5 escorted the patient to consult room #2 and the patient was provided a meal tray that included a bag of potato chips. Patient woke up from a nap, exited the consult room, entered into the hallway, proceeded to the exit door at the end of the hallway. The patient pushed at the exit door metal plate that enclosed the key lock for the exit door. At 1214 the patient attempted to open the exit door and at 1216 he hid behind the wall next to the exit door. He paced the hallway at 1217 and checked all the door handles on the hallway. At 1222 the patient was biting at the exit door key lock panel. At 1223 the patient was back in the consult room stood in the doorway and peeped into the hallway. At 1224 the patient was at the exit door and pulled at the door handle. At 1343 the patient positioned his mouth under a hand sanitizer dispenser, pressed the dispenser button and obtained contents from the dispenser into his mouth. The patient proceeded to the exit door key lock, placed his mouth over the key lock and expelled the contents from mouth onto the key lock. The patient repeated this behavior two more times. At 1403 the patient placed what appeared to be a portion/piece of the potato chip bag between the exit door and the door frame. He then pushed his back against the exit door but the door did not open. At 1409 PST #5 placed a Smart Serve tracking device (an electronic wrist band used by staff for patient observation and location during 15 minute checks) onto the patient’s left wrist. Patient walked to the exit door and rubbed the tracking device against the exit door frame. At 1416 he detached the hand sanitizer dispenser from the wall, placed the dispenser into his scrub pants and removed the screw from the wall where the dispenser was once mounted. At 1429 the patient had something in his hand and picked at the exit door key lock. Between 1431 to 1435 the patient tampered with the key lock and at times removed screws from his mouth to assist in the tampering. At 1441 the bottom of the key lock plate was bent upward, he pushed and placed his finger behind the plate, the exit door was unlocked and patient exited the door. There was not any staff on the hallway. At 1501 staff appeared on the hall, staff searched the rooms and at 1542 one hour and one minute post elopement a code walker was called. Interview on 02/27/2026 with the CEO (Chief Executive Officer) #7 at 1507 revealed patient #21 had not been located. Interview on 02/27/2026 at 0937 with the Director (Director of Admissions) #3 revealed staffing for the intake area consisted of 2 PSTs, at least 1 RN and Clinicians. Interview revealed the PSTs checked patients into the area and performed observations. The RN assessed patients, triaged walk-in patients and was the only staff that obtained orders. The Clinicians had master’s degrees; some were licensed and some were not. Clinicians performed administrative duties for insurance, referrals, meet with patients and assessed patients to determine patient’s behaviors. Interview revealed patient #21 was Involuntarily Committed (IVC’d), he had verbal altercations with several patients and was moved to the admissions hallway. The Director stated, “once moved to the admissions hall he should have been within line of sight ....PST staff usually determine when patients are separated. PST #4 performed observation last night and I am not sure if the RN was made aware patient was moved from waiting room to the hallway.” 2. Observation on 02/25/2026 at 0815 revealed facility staff COO (Chief Operations Officer) #10 and CEO #7 was talking to an un-named female located across the street from campus A. The staff was talking to the female and she was yelling at staff. The transport van arrived and staff from the van walked toward the front of the building. The female walked away from the staff to the corner and around the side of building out of view. The staff left the area; the transport driver entered the van and drove around the building. Medical record review on 02/27/2026 revealed patient #11 voluntarily arrived at campus A on 02/24/2026 at 2341 and was admitted to campus B ( South campus). Review of “ObservSMART ...BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET” dated 02/25/2026 revealed patient #11 was located at the nursing station at 0709 on the campus B with Q 15 minute checks. Documentation from 0724 to 0754 revealed “other” was the patient’s location and from 0739 to 0754 the patient’s behavior was “Crying/Tearful” Review revealed patient #11was “ ...Logged in ...2026-02-25 01:49...Patient Logged out to: Elopement...2026-02-25...08:01” Video review on 02/26/2026 at 1316 revealed on 02/25/2026 at 0735 patient #11 was admitted to campus B and was located in the 3 South West unit telephone room and she stood at the telephone room window and was looking towards the nursing station. BRS (Behavioral Response Specialist) #9 was standing on the outer side of the nursing station on the milieu. At 0735:44 patient #11exited the telephone room, approached the nursing station and stood behind the BRS #9. The BRS’s #9 back was toward patient #11. At 0736 the BRS #9 turned toward the unit hallway and reached into her left scrub pocket. The BRS’s #9 badge dropped to the floor and the staff member proceeded walking down the hallway. Patient #11 reached down and picked up the BRS’s #9 badge. The patient walked onto the unit hallway and at 0736:33 the patient was out of camera view. At 0743:40 7 minutes later the patient was seen exiting the buildings’ west side exit door to the outside. At 0743:46 the patient was seen walking outside the gym towards the front of the building. No additional video footage available. Interview on 02/25/2026 at 0905 with the CEO #7 revealed the female located outside the building across the street from campus A was identified as patient #11. The patient was voluntarily to campus B and post elopement patient #11 was IVC’d to campus A per the doctor’s orders. Interview on 02/25/2026 at 1336 with BRS#9 revealed she worked at campus B since June of 2025. Interview revealed on 02/25/2026 patient #11 “had been yelling, screaming and cursing at staff all morning.” Interview revealed the patient “was on the phone” and said, ‘we were holding her against her will.’ She revealed the phone is near the nursing station. The BRS #9 stated, “I was in and out of patient’s rooms performing environmental rounds. I thought the patient got my badge when I gathered linen out of the rooms and my badge must have fallen then” She stated “even though I was doing environmental rounds I was able to still hear her. At some point I did not hear her and I asked a peer if she saw the patient.” She said, ‘the last time I saw her she was on the phone.’ “I looked for her in the phone room, her bedroom, the shower and she was not there. I immediately reached across the nursing station desk, grabbed the walkie talkie and called code walker. Everyone was looking for her.” The BRS #9 stated “I was told to place the badge in my pocket prior to the elopement but staff always tucked the badges inside our scrub top. She stated, “I usually wear a zip up jacket and today I wore a hoodie and the badge was clipped to the outside of my scrubs.” Interview revealed “I was given my badge back by leadership.” Interview on 02/25/2026 at 1626 with the CEO #7 revealed patient #11 was located on Campus B third floor prior to the elopement. The CEO #7 revealed she arrived for work on 02/25/2026 around 0740 onto campus A. The CEO #7 was approached outside campus A by the COO #10 who reported ‘a lady’ outside campus A ‘was asking for her belongings.’ The COO #10 thought the lady had discharged. her. He checked the computer and realized she was a current patient (patient #11) at campus B. The CEO #7 & stated “I instructed staff to please get the provider on the phone. The provider gave orders to IVC her until provider could assess the patient. Transport staff placed her into the van. They used CPI (Crisis Prevention Intervention) to placed her into the van and she was taken to campus A to 2NB (2 North B - Acute co-ed unit). Interview revealed “staff are told to always wear badges out of sight.” The CEO #7 stated keys were being provided to all staff today to exit all outside doors.””

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 47421 Based on hospital policy, medical record reviews, hand-off communication notes, staff and physician interviews, the facility failed to ensure the medical record discharge date was accurately documented for 1 of 2 patient visits that were transferred and admitted to an outside facility (Patient #9) and the facility failed to ensure a patient’s medical record contained an appropriate patient identifier on each document in 3 of 21 medical records reviewed (Patient #7, 13, 19). The findings include: A. Review of the hospital policy titled “Documentation Requirements in the Medical Record” last revised 02/2025 revealed “ ...PURPOSE: To ensure ...accuracy of the documentation ... PROCEDURE: ... The attending physician is responsible for a complete and legible medical record for each patient. Its content shall be pertinent and current ... Signatures and Dates All entries in the medical record are to be dated, timed, and signed ...” Closed medical record review on 02/24/2026 revealed Patient #9 a 60-year-old female that was involuntarily committed on 12/17/2025 for psychosis. Review of Discharge Plan document dated 12/29/2025 at 1351 revealed the patient was scheduled for discharge home on 12/30/2025. On 12/29/2025 at 1600 the patient was transferred to Hospital C emergency room (ER) for an evaluation due to a low sodium level. Review of Discharge Summary dated 12/30/2025 revealed “We are planning to discharge the patient to outpatient treatment. In the meantime, we consulted medicine and found out that she has hyponatremia (low sodium) and she is sent to the ER, and she was admitted to the medical floor. Thus, she is discharged today from this facility.” Review of Patient #9 medical record revealed the patient was transferred and admitted to Hospital C on 12/29/2025, however the documented discharge summary date was 12/30/2025. Review of House Supervisor hand-off communication dated 12/29/2025 revealed “(Named Patient #9) sent to (named hospital) for abnormal labs, patient (pt) admitted around 2200.” Interview on 02/26/2026 at 1515 with MD #2 that dictated the discharge summary revealed the admission department documents the projected discharge date and the provider had no way to change that date once it’s documented in the system. When the provider begins to dictate the discharge summary the provider used the date that was already documented in the system, which in this case was 12/30/2025. Interview revealed that the provider considered the patient discharge date to be 12/30/2025 due to having 24 hours to discharge a patient from the system after a transfer. Interview on 02/26/2026 at 1720 with Director #1 revealed that when a patient was sent to the ER the facility staff accompany the patient. If the patient was discharged from the ER, the patient and staff would return to the facility, and the admission would not be interrupted. If a patient were admitted to the hospital, then the staff would return and alert the house supervisor of the patients admit status. Interview revealed that according to the house supervisor notes the patient’s hospital admit date was 12/29/2025 and that this should have been the patients discharge date from Campus A. Interview revealed that the discharge date for Patient #9 was incorrectly documented on the discharge summary. Interview on 02/27/2026 at 1125 with Admission Director #3 revealed that the admission department was responsible for entering the patient discharge date. However, when a patient was transferred to a hospital after hours or overnight, the house supervisor would be responsible for notifying the admissions department of the correct discharge date. B. Review of the hospital policy titled “Documentation Requirements in the Medical Record” last revised 02/2025 revealed “ ...PURPOSE: To ensure ...accuracy of the documentation ... Patient Identifying Data The patient medical record shall contain identifying data ... Each page maintained as part of the patient’s medical record should be [sic] include the patient’s full name, medical record number, date of admission, and the name of the attending physician ...” 1. Closed medical record review on 02/24/2026 revealed Patient #7 a 60-year-old female that was voluntarily committed on 12/24/2025 for hallucinations and paranoia. On 01/22/2026 the patient was stabilized and discharged to a group home. Record review revealed missing patient identifiers on patient medical record documents. Interview on 02/25/2026 at 1525 with Director #1 revealed that the admissions department prints off patient identifying stickers and sends them to the floor with the patient on admission. In the event that staff run out of patient stickers then the staff should call admissions to have them print more. Interview revealed that all documents in a patient’s medical record should have a patient identifying sticker and when no patient stickers were immediately available then a document should have at a minimum the patient’s full name and a second identifier written on it. 2. Open medical record review on 02/24/2026 revealed Patient #13 a 24-year-old female that was involuntarily committed on 02/12/2026 for bizarre behavior and aggression. As of 02/26/2026 the patient had not been discharged from the facility. Record review revealed missing patient identifiers on patient medical record documents. Interview on 02/25/2026 at 1525 with Director #1 revealed that the admissions department prints off patient identifying stickers and sends them to the floor with the patient on admission. In the event that staff run out of patient stickers then the staff should call admissions to have them print more. Interview revealed that all documents in a patient’s medical record should have a patient identifying sticker and when no patient stickers were immediately available then a document should have at a minimum the patient’s full name and a second identifier written on it. 3. Open medical record review on 02/24/2026 revealed Patient #19 a 73-year-old female that was involuntarily committed on 02/13/2026 for paranoia and aggression. As of 02/25/2026 the patient had not been discharged from the facility. Record review revealed missing patient identifiers on patient medical record documents. Interview on 02/25/2026 at 1525 with Director #1 revealed that the admissions department prints off patient identifying stickers and sends them to the floor with the patient on admission. In the event that staff run out of patient stickers then the staff should call admissions to have them print more. Interview revealed that all documents in a patient’s medical record should have a patient identifying sticker and when no patient stickers were immediately available then a document should have at a minimum the patient’s full name and a second identifier written on it.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 36956 Based on policy review, medical record reviews, video footage review, observation, and staff interviews, the facility failed to provide adequate professional and supportive staff to supervise, monitor, expedite a behavioral patient screening and prevent behavioral health patient elopement for 2 of 21 patients reviewed. (Patient #21, #11) Findings included: Policy review of “Plan for Professional Services (Provision of Care)” last approved 05/2024 revealed “Screening and Intake” “ ...Intake Screening and evaluations are performed by counselors or by a member of the clinical supervisory staff, social services staff, RN or active member of the medical staff, 24 hours a day, seven days a week.” 1. Medical record review on 02/27/2026 revealed on 02/26/2026 at 1125 patient #21 arrived at the facility admissions area on campus A (main campus) and was placed in the waiting area/lobby. The 36 year old male was Involuntary committed with Q (every) 15 minutes observation checks. Review of the “ADMISSIONS PRECAUTIONS CHECK SHEET” by PST (Patient Support Technician) #1 dated 02/26/2026 at 1125 revealed from 1130 to 1345 patient #21 was sitting in the lobby. At 1400 the patient was sitting in the hallway. Review revealed from 1415 to 1430 the patient was sitting in the lobby and from 1445 to 1545 the check sheet revealed the patient was sitting in the hallway. Review of the medical record revealed patient #21 was at the facility from 1125 until 1441 and there was not a notation by a RN regarding the patients’ needs and goals. Review revealed patient #21 was transferred from another facility. Review of transferring facility’s documentation revealed patient #21 was admitted to the transferring facility on 02/23/2026 with a diagnosis of “Acute psychosis with suicidal ideation.” Review of the “Psychosocial Flowsheet” dated 02/25/2026 from the transferring facility revealed Precautions...Elopement...02/25/26 1022”. Review of facility video footage on 02/27/2026 at 1333 for patient #21 revealed on 02/26/2026 at 1133 the patient entered the waiting area from the intake/admission foyer. The patient wore paper scrubs and six other patients were in the waiting room. There were two PSTs (Patient Support Technician) PST #4 and PST #5 located in the receptionist area with full view of the lobby. At 1137 the patient was pacing in the waiting room and at 1142 the patient approached and lingered at the door that lead into the intake admission foyer. At 1201 Clinician #6 (Social Worker)_ opened the waiting room door, motioned to patient to exit the room into the hallway after a verbal altercation with another patient. PST #5 escorted the patient to consult room #2 and the patient was provided a meal tray that included a bag of potato chips. Patient woke up from a nap, exited the consult room, entered into the hallway, proceeded to the exit door at the end of the hallway. The patient pushed at the exit door metal plate that enclosed the key lock for the exit door. At 1214 the patient attempted to open the exit door and at 1216 he hid behind the wall next to the exit door. He paced the hallway at 1217 and checked all the door handles on the hallway. At 1222 the patient was biting at the exit door key lock panel. At 1223 the patient was back in the consult room stood in the doorway and peeped into the hallway. At 1224 the patient was at the exit door and pulled at the door handle. At 1343 the patient positioned his mouth under a hand sanitizer dispenser, pressed the dispenser button and obtained contents from the dispenser into his mouth. The patient proceeded to the exit door key lock, placed his mouth over the key lock and expelled the contents from mouth onto the key lock. The patient repeated this behavior two more times. At 1403 the patient placed what appeared to be a portion/piece of the potato chip bag between the exit door and the door frame. He then pushed his back against the exit door but the door did not open. At 1409 PST #5 placed a Smart Serve tracking device (an electronic wrist band used by staff for patient observation and location during 15 minute checks) onto the patient’s left wrist. (2 hours and 44 minutes after the patient arrived). Patient walked to the exit door and rubbed the tracking device against the exit door frame. At 1416 he detached the hand sanitizer dispenser from the wall, placed the dispenser into his scrub pants and removed the screw from the wall where the dispenser was once mounted. At 1429 the patient had something in his hand and picked at the exit door key lock. Between 1431 to 1435 the patient tampered with the key lock and at times removed screws from his mouth to assist in the tampering. At 1441 the bottom of the key lock plate was bent upward, he pushed and placed his finger behind the plate, the exit door was unlocked and patient exited the door (3 hours and 16 minutes after arrival). There was not any staff on the hallway. At 1501 staff appeared on the hall, staff searched the rooms and at 1542 one hour and one minute post elopement a code walker was called. Interview on 02/27/2026 with the CEO (Chief Executive Officer) #7 at 1507 revealed patient #21 had not been located. Interview on 02/27/2026 at 0937 with the Director (Director of Admissions) #3 revealed staffing for the intake area consisted of 2 PSTs, at least 1 RN and Clinicians. Interview revealed the PSTs checked patients into the area and performed observations. The RN assessed patients, triaged walk-in patients and was the only staff that obtained orders. The Clinicians had master’s degrees; some were licensed and some were not. Clinicians performed administrative duties for insurance, referrals, meet with patients and assessed patients to determine patient’s behaviors. Interview revealed patient #21 was Involuntarily Committed (IVC’d), he had verbal altercations with several patients and was moved to the admissions hallway. The Director stated, “once moved to the admissions hall he should have been within line of sight ....PST staff usually determine when patients are separated. PST #4 performed observation last night and I am not sure if the RN was made aware patient was moved from waiting room to the hallway.” Interview revealed PST #5 was away from the intake area multiple times taking newly admitted patient’s belongings to the units. Interview on 02/27/2026 at1500 with the CEO #7 revealed the goal turnaround time for patients from intake to patient’s assigned room was 2 hours. 2. Observation on 02/25/2026 at 0815 revealed facility staff COO (Chief Operations Officer) #10 and CEO #7 was talking to an un-named female located across the street from campus A. The staff was talking to the female and she was yelling at staff. The transport van arrived and staff from the van walked toward the front of the building. The female walked away from the staff to the corner and around the side of building out of view. The staff left the area; the transport driver entered the van and drove around the building. Medical record review on 02/27/2026 revealed patient #11 voluntarily arrived at campus A on 02/24/2026 at 2341 and was admitted to campus B ( South campus). Review of “ObservSMART ...BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET” dated 02/25/2026 revealed patient #11 was located at the nursing station at 0709 on the campus B with Q 15 minute checks. Documentation from 0724 to 0754 revealed “other” was the patient’s location and from 0739 to 0754 the patient’s behavior was “Crying/Tearful” Review revealed patient #11was “ ...Logged in ...2026-02-25 01:49...Patient Logged out to: Elopement...2026-02-25...08:01” Video review on 02/26/2026 at 1316 revealed on 02/25/2026 at 0735 patient #11 was admitted to campus B and was located in the 3 South West unit telephone room and she stood at the telephone room window and was looking towards the nursing station. BRS (Behavioral Response Specialist) #9 was standing on the outer side of the nursing station on the milieu. At 0735:44 patient #11exited the telephone room, approached the nursing station and stood behind the BRS #9. The BRS’s #9 back was toward patient #11. At 0736 the BRS #9 turned toward the unit hallway and reached into her left scrub pocket. The BRS’s #9 badge dropped to the floor and the staff member proceeded walking down the hallway. Patient #11 reached down and picked up the BRS’s #9 badge. The patient walked onto the unit hallway and at 0736:33 the patient was out of camera view. At 0743:40 7 minutes later the patient was seen exiting the buildings’ west side exit door to the outside. At 0743:46 the patient was seen walking outside the gym towards the front of the building. No additional video footage available. Interview on 02/25/2026 at 0905 with the CEO #7 revealed the female located outside the building across the street from campus A was identified as patient #11. The patient was voluntarily to campus B and post elopement patient #11 was IVC’d to campus A per the doctor’s orders. Interview on 02/25/2026 at 1336 with BRS#9 revealed she worked at campus B since June of 2025. Interview revealed on 02/25/2026 patient #11 “had been yelling, screaming and cursing at staff all morning.” Interview revealed the patient “was on the phone” and said, ‘we were holding her against her will.’ She revealed the phone is near the nursing station. The BRS #9 stated, “I was in and out of patient’s rooms performing environmental rounds. I thought the patient got my badge when I gathered linen out of the rooms and my badge must have fallen then” She stated “even though I was doing environmental rounds I was able to still hear her. At some point I did not hear her and I asked a peer if she saw the patient.” She said, ‘the last time I saw her she was on the phone.’ “I looked for her in the phone room, her bedroom, the shower and she was not there. I immediately reached across the nursing station desk, grabbed the walkie talkie and called code walker. Everyone was looking for her.” The BRS #9 stated “I was told to place the badge in my pocket prior to the elopement but staff always tucked the badges inside our scrub top. She stated, “I usually wear a zip up jacket and today I wore a hoodie and the badge was clipped to the outside of my scrubs.” Interview revealed “I was given my badge back by leadership.” Interview on 02/25/2026 at 1626 with the CEO #7 revealed patient #11 was located on Campus B third floor prior to the elopement. The CEO #7 revealed she arrived for work on 02/25/2026 around 0740 onto campus A. The CEO #7 was approached outside campus A by the COO #10 who reported ‘a lady’ outside campus A ‘was asking for her belongings.’ The COO #10 thought the lady had being discharged. He checked the computer and realized she was a current patient (patient #11) at campus B. The CEO #7 stated “I instructed staff to please get the provider on the phone. The provider gave orders to IVC her until provider could assess the patient. Transport staff placed her into the van. They used CPI (Crisis Prevention Intervention) to placed her into the van and she was taken to campus A to 2NB (2 North B - Acute co-ed unit). Interview revealed “staff are told to always wear badges out of sight.” The CEO #7 stated keys were being provided to all staff today to exit all outside doors.” NC00235746, NC00235956, NC00233794”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 41345 Based on policy and procedure review, medical record reviews, safety rounding sheets review and staff interviews the nursing staff failed to obtain an order for recommended medications following an ED (emergency department) visit for 1 of 4 patients that went to the ED (#16); and failed to conduct a patient room search per physician order and document contraband searches per facility policy for 1 of 1 (Patient #1) sampled record with contraband search per physician orders. The findings include: 1. Review of policy “Sexual Aggression and Victimization Prevention and Precautions”, revised 03/2025 was received from facility staff on October 14, 2025, at approximately 0900. The policy stated ...” discovery of sexual allegation between patient/patient ...immediately separate patients, secure the area, preserve evidence, initiate investigation, prepare patients for transport to ER (emergency room) complete incident report ...”. Closed medical record review was conducted on October 14, 2025. Patient #16 was admitted to the facility on 07/15/2025 with a diagnosis of psychosis and SI (suicidal ideation) involuntary. It was noted that Patient #16 was sexually active with Patient #4 in the admissions lobby bathroom prior to being admitted to the facility. Medical treatment plan was reviewed and identified a patient with high-risk alerts for sexual precautions due to bathroom incident. Patient #16 was on 15 min checks per policy. Patient #16 was sent out to an emergency department (ED) for evaluation and treatment. Review of the ED discharge instructions for Patient #16 included the following labs CBC (complete blood count), CMP (complete metabolic panel), HIV antigen/antibody with reflex, magnesium level, syphilis screen, eGFR (measures how the kidneys are doing), and hCG (pregnancy test). The following medications were given in the ED Truvada (medication used to treat pre-exposure prophylaxis to prevent HIV) 200 mg (milligrams) -300 mg take 1 tablet by mouth daily; and raltegravir (medication used to treat HIV infection) 400 mg take 1 table by mouth 2 times a day. Review of the discharge summary revealed - pick up these medications at the named outpatient pharmacy. Further medical record revealed these medications were not given to the patient at the facility during the hospitalization. Interview with MD #5 on 10/14/2025 at 1525 revealed, “it looks like we didn’t start it, the medicine wasn’t started here, we missed it”. Interview with RN #6 on 10/15/2025 at 1800 revealed, “I remember assessing her and I admitted her to the unit, I called the physician and she was sent out to the ED to be evaluated, I thought she would come back with a cream, I don’t remember any other medicines ...usually I look at the discharge summary and call the nurse practitioner on call and I put medicines in the system once I talk to them and get an order”. 26622 2. Review on 10/16/2025 of the facility policy titled “Contraband Search Guidelines” revised 5/2022, revealed “... “IV. Room Search - Room searches will be done for specific patient rooms when there is reasonable cause to believe the patient may possess an item, which is potentially dangerous. ... A room search will be conducted in the following manner: a. A minimum of two staff members will conduct the search. b. Inform the patient(s) of the search and the reason for the search beforehand. c. The patient has the right to be present during the search of their rooms, unless contraindicated. Patient will not participate in the search. d. Examine all chairs, cushions, beds, dressers, stands, closets and/or other furniture; Check under, behind and on top of furniture and under mattresses and in bed linens. e. Examine light and lamp fixtures, wall grills and covers, heating and air conditioning units. f. Examine all bathroom fixtures and fitting as well as cabinets, sinks, paper dispensers, etc. g. Check patient drawers, linens, suitcases, folded and dirty clothing, shoes, purses/bags, and anything else which something could be hidden. Articles such as books, purses, and hygiene articles should also be thoroughly inspected. Keep in mind that people intending to hide something can sometimes be very resourceful. Each and any place, which can be used to hide potentially dangerous articles. h. All articles and items should be returned to their original place after examined. i. documentation in the patient’s medical record will be completed when a room search is performed. this documentation should include the reasons for conducting the search, the results of the search, the disposition of any dangerous materials found and the patient’s response. ...” Closed medical record review on 10/14/2025 for Patient #1 revealed a 15-year-old female involuntary admitted to the facility on 06/23/2025 at 1850 with a diagnosis of Major Depressive Disorder and suicidal ideations. Review of the medical record for Patient #1 revealed a physician order written on 07/17/2025 at 0400 (no stop date/time) for “Contraband searches of patient’s room and person at least once per shift.” Review of the medical record revealed no documented evidence of room searches conducted from 07/17/2025 through 07/23/2025. The record review revealed a physician order written on 07/24/2025 at 1225 (no stop date/time) for “Contraband searches of patient’s room and person at least once per shift.” Review of the medical record revealed no documented evidence of room searches conducted from 07/24/2025 through 08/08/2025 (date of discharge). Review of the 7 AM and 7 PM environmental safety rounding sheets, conducted by nurses and/or mental health technicians, for the adolescent female unit from 07/17/2025 through 08/08/2025 (date of discharge) revealed no documented 7 AM shift safety round checks on 07/17/2025, 07/18/2025, 07/19/2025, 07/20/2025, 07/21/2025, 07/24/2025, 07/25/2025, 07/27/2025, 07/28/2025, 07/29/2025, 07/31/2025, 08/01/2025, 08/02/2025, 08/03/2025, 08/05/2025, 08/06/2025, and 08/07/2025 (17 of 22 contraband searches). Further review of the safety rounding sheets revealed no documented 7 PM shift safety round checks on 07/17/2025, 07/19/2025, 07/20/2025, 07/24/2025, 07/25/2025, 07/31/2025, and 08/01/2025 (7 of 22 contraband searches). Review of the safety rounding sheets dated 07/22/2025 revealed the 7 AM and 7 PM safety rounds were conducted by the same mental health technician with no documentation of the nurse review signature. Review of the shift safety rounding sheets dated 07/23/2025, 07/26/2025 and 08/07/2025 (3 of 22 contraband searches) revealed no nurse review signature documented for the 7 AM shift safety rounds. Interview on 10/16/2025 at 1339 with MHT #10 revealed the mental health technicians were expected to complete the environmental safety rounding sheets once a shift. The technicians checked for contraband such as pen, pencil, crayon, etc. The safety checklists were placed on a clipboard on the unit after completion and handed off to the on-coming shift. The interview revealed the violations sheet, census and environmental rounding sheets with the environmental sheets indicating what actions were taken. All three sheets were placed on the clipboard and kept on the unit in a notebook. Interview on 10/17/2025 at 1300 with RN #9 and RN #4 revealed the staff were expected to document the environmental safety rounding sheets once each shift. The safety rounding sheets should be signed by the mental health technician and reviewed and signed by the Registered Nurse. The interview revealed that the staff were not expected to check the patient’s clothing in the room. Interview revealed the staff failed to follow the facility policy for contraband checks in a patient room when ordered by the physician. Interview revealed the staff failed to follow the physician order to conduct contraband searches of patient’s room and person at least once per shift.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 26622 Based on review of hospital policies, medical records and staff interviews, hospital staff failed to ensure a Master Treatment Plan (MTP) was completed and/or updated for 2 of 7 master treatment plans reviewed (Pt #1, Pt #21); and failed to include a medical diagnosis on the Master Treatment Plan (MTP) for 1 of 2 pregnant patient medical records reviewed (#19). The findings include: Review on 10/14/2025 of the hospital policy titled “Master Treatment Plan & Master Treatment Plan Update” revised 03/2023, revealed “Social Services staff: *is responsible for completing the Master Treatment Plan within 72 hours of admission... ... *is responsible for completing Master Treatment Plan Updates at a minimum of every 7-days from the date that the Master Treatment Plan is signed. ...” Review on 10/25/2025 of the hospital policy titled “Documentation Requirements in the Medical Record” revised 02/2025 revealed, “... Treatment Plan ... 3. The multi-disciplinary treatment team shall develop the Master Treatment Plan within seventy-two (72) hours of admission... 3. ... based on a comprehensive assessment of the patient’s presenting problems, physical health, emotional and behavioral status .... 15. The Treatment Plan shall be reviewed and updated as frequently as clinically indicated by the patient’s anticipated length of stay and treatment issues, but at a minimum, reviewed weekly. ...” 1. Closed medical record review on 10/14/2025 for Patient #1 revealed a 15-year-old female involuntary admitted to the facility on 06/23/2025 at 1850 with a diagnosis of Major Depressive Disorder and suicidal ideations. Review of the medical record revealed the interdisciplinary treatment plan was documented and signed on 07/02/2025 (9 days after admission). Review of the medical record revealed the facility failed to document a master treatment plan within seventy-two (72) hours of admission. Patient #1 was transported and admitted to an acute-care hospital on 07/05/2025. Patient #1 was readmitted to the facility on 07/07/2025 after discharge from acute-care hospital. Review of the medical record for Patient #1 revealed the Patient was readmitted to the facility after discharge from the acute-care hospital on 07/07/2025 at 1456. The Master Treatment Plan was initiated on 07/08/2025, updated on 07/15/2025, 07/22/2025 and on 08/02/2025 (4 days late). Record review failed to reveal evidence of the seven (7) day Master Treatment Plan update on 07/29/2025. Patient #1 was discharged to the DSS legal guardian on 08/08/2025 at 1035. Interview on 10/15/2025 at 1000 with RN #4 revealed that the initial master treatment plan should be completed within 72 hours of admission and updated every seven days. 34065 2. Review of an open medical record for Patient #21 revealed a 25-year-old male admitted on 10/10/2025 with a diagnosis of Schizophrenia with self-harm behaviors. Review revealed the Master Treatment Plan was dated 10/14/2025, 4 days after admission. Interview on 10/14/2025 at 1515 with Therapist #3 revealed the Master Treatment Plan was late. Interview revealed “I did not have time. I had 6-8 MTP’s to do.” Interview on 10/17/2025 at 1330 with DCS #1 revealed the MTP was late. The MTP should have been completed within 72 hours after admission. Interview revealed the policy was not followed. 3. Review of a closed medical record for Patient #19 revealed a 42-year-old female admitted on 07/25/2025 for psychosis. Review revealed Patient #19 was pregnant in the first trimester. Review of the Master Treatment Plan Master Problem List dated 07/28/2025 revealed no diagnosis listed in Acute Medical Problems/Medical Problems section. Review of the medical record revealed Patient #19 had been evaluated by the medical team on 07/26/2025 for “spotting and abdominal cramping.” Interview on 10/17/2025 at 1330 with DCS (Director of Clinical Services) #1 revealed the pregnancy should have been listed on the medical problems list. Interview revealed the policy was not followed. NC00233226; NC00233899, NC00232603; NC00233712; NC00233733; NC00233655; NC00233229; NC00232086; NC00233883”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 16369 Based on policy and procedure review, Medical Staff Bylaws, Rules and Regulations, medical contract, video camera review, staffing census sheets, credentialing file reviews, on-call schedule review, medical record review and staff interviews, the hospital’s governing body failed to provide oversight and have systems in place to ensure medical staff provided quality care and practiced within their approved privileges; ensure the protection and promotion of patient’s rights to provide a safe environment that was free from abuse and neglect for behavioral health patients; failed to have an organized nursing service to supervise and meet patient care and safety needs; and failed to demonstrate and document the degree and intensity of the individualized treatment provided to behavioral health patients. The findings include: 1. The hospital failed to provide a medical consultation for a patient with a suspected injury in 1 of 14 sampled patients with medical consultation orders (Pt #30). ~cross refer to 482.12(a)(5) Governing Body - Medical Staff Accountability: tag A0049 2. Hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19). ~cross refer to 482.13(c)(2) Patients’ Rights - Care in a Safe Setting: tag A0144 3. Hospital staff failed to prevent verbal abuse to patients by hospital staff for 1 of 1 sampled medical records ( Pt #52). ~cross refer to 482.13(c)(3) Patients’ Rights - Free from Abuse/Harassment: tag A0145 4. Hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19). ~cross refer to 483.23(b)(3) Nursing Services - RN Supervision of Nursing Care: tag A0395 5. Hospital leadership failed to ensure Advanced Practice Providers (APPs) provided age-specific care and treatment based on their delineated privileges for 4 of 4 APP credentialing files reviewed (Staff #27, Staff #28, Staff #29, Staff #4). ~cross refer to 483.22 Medical Staff: tag A0339 6. The medical staff failed to conduct reappraisals of appointment and privileges granted for 2 of 6 sampled credentialing files reviewed (Staff #29, Staff #4). ~cross refer to 483.22 Medical Staff: tag A0340 7. The hospital failed to ensure that medications were kept in a secure area. ~cross refer to 483.?? Pharmaceutical Services: tag A0502 8. Hospital staff failed to ensure a Master Treatment Plan was completed and/or updated for 21 of 72 medical records reviewed (Pt #34, #35, #39, #52, #54, #59, #44, #46, #19, #40, #24, #26, #10, , #39, #12, #25, #28, #31, #14, #68 and #16). ~cross refer to 482.61(c)(1) Treatment Plan: Tag A1640 9. Hospital staff failed to ensure short-term and long-range goals were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #38). ~cross refer to 482.61(c)(1)(ii) Treatment Plan - Goals: Tag A1642 10. Hospital staff failed to ensure a Master Treatment Plan with specific treatment modalities were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #60). ~cross refer to 482.61(c)(1)(iii) Treatment Plan - Modalities: Tag A1643 11. Hospital failed to ensure treatment team responsibilities were completed for 11 of 72 medical records reviewed. (Pt #12, #31, #32, #25, #29, #28, #14, #59, #54, #38, and #9). ~cross refer to 482.61(c)(1)(iv) Treatment Plan - Team Responsibilities: Tag A1644 12. Hospital staff failed to document daily group therapy for 4 of 72 medical records reviewed (Pt #52, #35, #34, #33). ~cross refer to 482.61(c)(2) Document Therapeutic Efforts: Tag A1650 13. Hospital staff failed to ensure Social Services Progress Notes were completed for 11 of 72 medical records reviewed (Pt #34, #35, #54, #9, #10, #30, #39, #67, #25, #28, #16). ~cross refer to 482.61(d) Recording Progress Notes: Tag A1655 14. Hospital failed to ensure patients received follow up appointments and prescriptions prior to patients being discharged for 3 of 59 sampled closed medical records (Pt #60, #68, #36). ~cross refer to 482.61(e) Discharge Summary - Recommendations: Tag A1671”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 16369 Based on policy and procedure review, video camera review, staffing census sheets, medical record review and staff interviews, the facility failed to protect and promote patients’ rights by neglecting to ensure a safe environment for the delivery of care to adolescent behavioral health patients with a known history of aggression. Seven (7) adolescent female behavioral health patients were involved in an incident on December 22, 2024, which required police intervention and transfer of patients to an acute hospital. Hospital staff failed to honor patient’s rights by not notifying patients legal guardians about treatment decisions, injuries and aggressive incidents; failing to ensure contraband was not accessible to patients; and failing to prevent verbal abuse from staff. The findings include: 1. Hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19). ~cross refer to 482.13(c)(2) Patients’ Rights - Care in a Safe Setting: tag A0144 2. Hospital staff failed to honor patient’s rights by failing to establish legal guardianship identification, notify a patient’s legal guardian of treatment decisions, patient injuries, altercations, and timely notification of an elopement for 5 of 72 sampled patient records reviewed (#9, 10, 35, 43, 11). ~cross refer to 482.13(b)(2) Patients’ Rights - Informed Consent: tag A0131 3. Hospital staff failed to ensure safety requirements were met by failing to remove and prevent patient access to contraband items used to perform self harm in 2 of 2 sampled patients (Pt #30, #28). ~cross refer to 482.13(c) Patients’ Rights - Privacy and Safety: tag A0142 4. Hospital staff failed to prevent verbal abuse to patients by hospital staff for 1 of 1 sampled medical records ( Pt #52). ~cross refer to 482.13(c)(3) Patients’ Rights - Free from Abuse/Harassment: tag A0145”

“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: 16369 Based on policy and procedure review, video camera review, staffing census sheets, medical record review and staff interviews, the facility’s nursing staff failed to have an effective nursing service providing oversight of day-to-day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to behavioral health patients. The findings include: 1. Hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19). ~cross refer to 483.23(b)(3) Nursing Services - RN Supervision of Nursing Care: tag A0395 2. Hospital staff failed to provide and/or assist with hygiene needs for 1 of 1 patients observed with lack of proper hygiene; and failed to evaluate a patient for falls risk in 1 of 1 patients observed with unsteady gait. (Patient #40). ~cross refer to 483.23(b)(6) Nursing Services - Supervision of Contract Staff: tag A0398”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 16369 Based on review of hospital policies, medical records and staff interviews, hospital staff failed to demonstrate and document the degree and intensity of the individualized treatment provided to behavioral health patients. The findings include: 1. Hospital staff failed to ensure a Master Treatment Plan was completed and/or updated for 21 of 72 medical records reviewed (Pt #34, #35, #39, #52, #54, #59, #44, #46, #19, #40, #24, #26, #10, , #39, #12, #25, #28, #31, #14, #68 and #16). ~cross refer to 482.61(c)(1) Treatment Plan: Tag A1640 2. Hospital staff failed to ensure short-term and long-range goals were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #38). ~cross refer to 482.61(c)(1)(ii) Treatment Plan - Goals: Tag A1642 3. Hospital staff failed to ensure a Master Treatment Plan with specific treatment modalities were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #60). ~cross refer to 482.61(c)(1)(iii) Treatment Plan - Modalities: Tag A1643 4. Hospital failed to ensure treatment team responsibilities were completed for 11 of 72 medical records reviewed. (Pt #12, #31, #32, #25, #29, #28, #14, #59, #54, #38, and #9). ~cross refer to 482.61(c)(1)(iv) Treatment Plan - Team Responsibilities: Tag A1644 5. Hospital staff failed to document daily group therapy for 4 of 72 medical records reviewed (Pt #52, #35, #34, #33). ~cross refer to 482.61(c)(2) Document Therapeutic Efforts: Tag A1650 6. Hospital staff failed to ensure Social Services Progress Notes were completed for 11 of 72 medical records reviewed (Pt #34, #35, #54, #9, #10, #30, #39, #67, #25, #28, #16). ~cross refer to 482.61(d) Recording Progress Notes: Tag A1655 7. Hospital failed to ensure patients received follow up appointments and prescriptions prior to patients being discharged for 3 of 59 sampled closed medical records (Pt #60, #68, #36). ~cross refer to 482.61(e) Discharge Summary - Recommendations: Tag A1671”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 50318 Based on review of Medical Staff Bylaws, Medical Staff Rules and Regulations, medical contract, hospital policy, medical record, and staff interviews, the hospital failed to provide a medical consultation for a patient with a suspected injury in 1 of 14 sampled patients with medical consultation orders (Pt #30). The findings include: Review on 01/28/2025 of Medical Staff Bylaws adopted 01/29/2024 revealed, “ ...Basic Responsibilities of Medical Staff Membership... F. To work cooperatively with other medical staff members, nurses, and allied members of the professional staff, facility administration, and all others involved in the patient care, so as not to affect patient care adversely; and to assure that each patient is provided with the same level and quality of patient care... “ Review on 01/28/2025 of Medical Staff Rules and Regulations, revised on 04/2024, revealed, “ ...10. Medical/Psychiatric Consultations...10.2 Progress notes must provide the reason for the consultation, a written opinion by the consultant, and recommendations for further care ... 10.6 A satisfactory consultation includes examination of the patient and the medical record. A progress note and formal report, signed by the consultant, must be included in the medical records ... “ Review on 01/28/2025 of “Collaborative Practice Agreement, Advanced Practice Provider” (APP) revealed, “ ... 4. Medical Treatments, Tests, and Procedures ... a) Perform a comprehensive, age-appropriate examination of the patient based on the reason for the visit (to include gathering subjective and objective data related to chief complaint, history of present illness, past medical history, review of systems, family and social history, and current medications) ... d) Record progress notes as indicated ...” Review on 01/28/2025 of hospital policy “Documentation Requirements In The Medical Record,” last revised 11/2023, revealed, “... Medical Staff (Physicians) ... 10. Consultation reports should contain a written opinion by the consultant that reflects an actual examination of the patient and a review of the medical record and should be completed within twenty-four (24) hours... Physician Assistants/Family Nurse Practitioners... 4. Subsequent documentation regarding medical records and/or follow-up is to be documented in the progress notes... Progress Notes 1. The Progress Notes are integrated and each discipline documents in chronological order, events as they occur... Progress Note entries are to address the problem, evaluation, assessment/findings and therapeutic plan as appropriate...” Closed medical record review on 01/14/2025 for Patient #30 (Pt) revealed a 14-year-old patient voluntarily admitted on 05/24/2024 for disruptive mood dysregulation (a disorder characterized with ongoing irritability, anger, and frequent, intense temper outbursts) and oppositional defiant disorder (a disorder characterized by uncooperative, defiant, and hostile behavior to authority figures). Pt #30 endorsed high risk behaviors including running away from home, was gone for eight days, and had been using marijuana. Nurse Progress Note on 07/06/2024 at 2300 revealed, Pt #30 became triggered by her peers and began to strike the wall of the day room with her right hand. Pt #30 complained of right hand pain but had good range of motion; no redness or bruising was noted. “Tylenol PO (oral) times two” (no dosage specified) was administered for pain. Nurse Progress Note on 07/07/2024 at 0745 revealed, Pt #30 complained of 7 out of 10 pain (0 being no pain and 10 being the highest level of pain) to her right hand with slight swelling noted to her fifth digit and palm of her hand but refused pain medications at that time. A medical consultation (consult) order was placed for right wrist/hand pain on 07/07/2024 at 0803 by Staff #27 and electronically signed by Staff #3 on 07/08/2024 at 0906. Pt #30 was discharged home on 07/18/2024. Record review failed to reveal documentation of a medical consult being completed or any progress notes related to a medical consult. Interview on 01/27/2024 at 1313 with Staff #31 revealed there was no consult or notes that Staff #31 could locate regarding Pt #30’s medical consult order. Interview on 01/27/2025 at 1505 with Staff #18 revealed when a medical consult order was placed, a copy was automatically printed to the medical providers’ office/copier. Staff #18 revealed they would then have 48 hours to complete the consult, but typically patients were seen within 24 hours. Staff #18 revealed Pt #30’s order was “incorrectly” placed, as the medical Providers could not consult themselves; it would need to be ordered by Staff #3 instead. Staff #18 revealed Staff #27 should have contacted Staff #3 to follow-up on this medical consult, and if it was still needed, the consult would have to be re-ordered “correctly” and then the patient would be seen. Telephone Interview on 01/28/2025 at 1000 with Staff #27 revealed Staff #27 worked part-time covering medical consults and would be on-site during the day when covering consults, including the weekends. Staff #27 covered all populations/campuses (adult and children) when on-call or on-site for medical consults. Staff #27 revealed an order would be placed for the patient who needed a consult, and the patient would typically be seen the same day. If Staff #27 was no longer on-site, the staff could call for a consult, and directives would be given to Nursing over the phone, or if it was urgent, Staff #27 would direct Nursing to send the patient to the ED (Emergency Department). Staff#27 did not recall Pt #30 and could not recall if a consult had been completed for Pt #30.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50318 Based on review of hospital policies, medical records and staff interviews, hospital staff failed to honor patient’s rights by failing to establish legal guardianship identification, notify patient’s legal guardian of treatment decisions, patient injuries, altercations, and timely notification of an elopement for 5 of 72 sampled patient records reviewed (#9, 10, 35, 43, 11). The findings include: Review on 01/13/2025 of hospital policy, “Assessment and Admissions Process,” last reviewed on 03/2022 revealed, “... An authorization for treatment is obtained by the patient or legal guardian at the time of admission...4.2.6 In the event a patient identifies that he/she has a legal guardian, the Admissions Specialist shall attempt to notify the legal guardian, notating the notification on the Admissions Assessment...5.0 The Admissions Specialist verbally reviews and completes all admission documents with the patient or guardian. 5.1 The patient or guardian acknowledges admission by signing the Consent for Treatment and Conditions of Admission...” Review on 01/09/2025 of hospital policy, “Discharge Planning,” last reviewed on 10/2022 revealed, “... 2. The Therapist/Case Manager discusses discharge options with the patient and legal guardian, if applicable...3. Reviews preliminary discharge plan and discharge criteria with patient and guardian (if applicable). 4. Obtains the patient’s or legal guardian (if applicable) signature on a Release of Information for the provider who the patient will see after discharge... Discharge Process. Talk to patients and guardians about taking copies of the discharge plan to their first appointments. Safety Crisis Plan completed with patient and family/support person. A copy provided to the patient, support person, and for the medical record...” Review on 01/23/2025 of hospital policy “UNTOWARD EVENTS - INFORMING FAMILIES,” last reviewed 01/2020, revealed, “... If the patient (both adults and children) has a legal guardian, they will be notified of significant untoward events. Significant untoward events include:...2. Elopement...Procedure ... 3. The nurse will contact the family as quickly as possible. If unable to contact, repeated attempts will be made and so documented in the patient’s medical record. 4. All attempted and actual contacts with the family will be documented in the patient’s medical record.” 1. Closed medical record review on 01/09/2025 for Pt #9 revealed a 32-year-old patient who was involuntarily committed on 05/11/2024 with a diagnosis of schizophrenia (a disorder that affects a person’s ability to think, feel, and behave) and increased aggression (violent attacking behavior or attitude toward another person) with staff at his group home. Review of paperwork sent from Facility B revealed, Pt #9 had a legal guardian. Admissions High Risk Notification Alert on 05/11/2024 at 2113 revealed, “Adult with Legal Guardian: No.” The Interdisciplinary Master Treatment Plan (MTP) was signed by the Treatment Team (Nurse, Therapist, and Nurse Practitioner) on 05/14/2024, and the patient and/or guardian signature was blank. Comprehensive Clinical Assessment at 1733 revealed the section titled, Patient is in the Custody of: with check boxes for self, parent, legal guardian, or other, was blank. Assessment of Family/Support Attitudes indicated Pt #9 did not provide permission for contact with family/support person. Social Services Progress Note at 1740 revealed Pt #9 had some social concerns and would need social resources post-discharge for housing and mental health. Review failed to reveal evidence of any follow-up, additional Social Services Progress Notes, or discussion with Pt #9’s legal guardian. Discharge Safety Plan was initiated on 05/17/2024 at 1545 and revealed, “Were family, friends, or caregivers of the patient invited to participate?” with a yes or no checkbox, was blank. Pt #9 was discharged to a shelter on 05/20/2024. Record review failed to reveal evidence of verification of Pt #9’s legal guardian. Interview on 01/15/2025 at 1118 with Staff #34 revealed in May 2024, an outside source was reviewing paperwork from other facilities in admissions, and they should have notated on the High Risk Notification form if there was a legal guardian and then try to contact the guardian. Staff #34 revealed, “it’s our due diligence to check and confirm legal guardians” as patients were not always reliable and could present as psychotic. Staff #34 revealed based off observation, Pt #9 had slight IDD (intellectual or developmental disability), but it was not documented, and Pt #9 needed social resources, such as housing and employment. Staff #34 acknowledged there was no documentation in Pt #9’s medical record regarding the patient going back to his group home and no information regarding verification of a legal guardian. Interview on 01/17/2025 at 0931 with Staff #39 revealed it was admissions’ responsibility to verify a patient’s legal guardian, especially if there was a discrepancy in paperwork from other facilities and their admissions paperwork. Staff #39 revealed a third party group was previously reviewing paperwork in May 2024, but there were a lot of discrepancies with them, and their contract was ended on 12/31/2024. Staff #39 revealed this group was primarily determining if a patient met criteria for admissions. Staff #39 revealed, with the previous process, it could have fallen through the cracks for determining Pt #9’s legal guardian. 2. Closed medical record review on 01/09/2025 for Pt #10 revealed a 27-year-old patient who was involuntarily committed on 10/25/2024 with a diagnosis of schizophrenia with aggressive behaviors and homicidal ideations (HI - harming others). Admissions High Risk Notification Alert on 10/25/2024 at 1345 revealed, “Adult with Legal Guardian: Yes,” with handwritten name and phone number listed. History & Psychiatric Evaluation completed on 10/25/2024 at 1400 revealed a voicemail was left with (name, phone number), they were unable to reach the legal guardian, and home medication would be continued at that time. Pt #10 was administered a chemical restraint (medications given to control a patient’s behavior) on 10/26/2024 at 0958 for combative, threatening, aggressive, and destructive behaviors. Notification to family/guardian was marked as “No” on the restraint paperwork. A Nursing Note related to this incident revealed, Pt #10 “does not have legal guardian.” Daily Nursing Progress Note at 1130 revealed, Staff #40 contacted (name, phone number) who from their documents was indicated as the legal document, but (named) stated they were not the legal guardian and provided the name and phone number of Pt #10’s case manager. Comprehensive Clinical Assessment on 10/28/2024 at 1045 revealed Pt #10’s case manager was contacted at 0947, but the Assessment of Family/Support Attitudes related to baseline, concerns, and goals was blank. Integrated Summary and Recommendations revealed Pt #10 reported having a social worker/case manager, and the tentative discharge plan was to discharge to his past residence or find another placement if he could not return. The Interdisciplinary Master Treatment Plan (MTP) was signed by the Psychiatrist, Therapist, Nurse, and Pt #10 on 10/28/2024, and the legal guardian phone review section was blank. A consent for psychotropic medications (medications used to treat mental health conditions) was signed by Staff #44 on 11/01/2024 and noted phone consent by a “new legal guardian.” Discharge Summary: Disposition and After Care on 11/05/2024 revealed, no disposition or aftercare follow-up appointment was found in the chart. Pt #10 was discharged on 11/05/2024. Social Service Progress Note on 11/05/2024 at 1600 revealed Pt #10 was discharged around 1600 and prior to discharge, the group home was contacted for transportation, but they had not yet left to pick up Pt #10. Staff #35 offered to provide cab transportation to expedite discharge, which was approved by the (named) group home manager. At approximately 2100, (named) group home manager contacted Staff #35 that Pt #10 had not arrived at the group home. Staff #35 then spoke with the cab company who informed them that Pt #10 became threatening, aggressive, and exited the vehicle. Staff #35 contacted (named county) Sheriff and then contacted Pt #10’s legal guardian and left a message. Record review failed to reveal evidence of discussion with Pt #10’s legal guardian regarding treatment and discharge plans, including the change in transportation. Interview on 01/10/2025 at 1014 with Staff #8 revealed the Therapists should contact patients’ legal guardians and go over all the paperwork with them. Staff #8 revealed it might take a couple days to establish who the legal guardian was, and they should reach out to the House Supervisor if they were unable to contact a legal guardian. Staff f#8 was unsure when the legal guardian was correctly identified for Pt #10. Staff #8 revealed the legal guardian should have been contacted for Pt #10’s chemical restraint. Staff #8 revealed Staff #35 had been in contact with Pt #10’s legal guardian but acknowledged the discharge paperwork was not in the medical record to verify who was contacted. Interview on 01/15/2025 at 1447 with Staff #46 revealed there was not a specific process in admissions to properly verify a patient’s legal guardian. Admissions would request this information from the sending facility, but there were instances where it was not sent to them and they used what they had, such as the patient themselves. Staff #46 revealed, this could often be confusing, and admissions was not informed after the fact if there were any issues or changes with the legal guardian. Staff #35 no longer worked at the facility. 50111 3. Closed medical record review on 01/15/2025 for Patient #35 (Pt) revealed a 44-year-old male admitted to the hospital on 09/25/2024 at 2308 with a diagnosis of schizophrenia (a disorder that affects a person’s ability to think, feel, and behave clearly) and a secondary diagnosis of autism (a lifelong developmental disability). Record review revealed Pt #35 had a legal guardian. Review of the Nurse Note on 09/26/2024 at 0530 revealed, “0445 AM patient was punched by the roommate ... The current patient sustained facial injuries: Bridge of the nose, a bruise in the upper side of the eye. Scratches were noted on the patient (sic) right nares. First Aid provided. Roommate was moved to a different room. Supervisor and attending were notified ...” Review of the Medicine Consult Note on 09/26/2024 at 1440 revealed, “... Blunt head trauma w/ (with) injuries appreciated w/ swelling of nasal bridge. XR (X-Ray - an imaging technique used to obtain pictures inside the body) facial ordered ...” Review of the Radiology Report on 09/27/2024 at 1307 revealed, “No acute fracture or dislocation.” Medical record review failed to reveal documentation of legal guardian notification of Pt #35’s injury. Pt #35 was discharged home on 10/10/2024 at 1420. Interview on 01/17/2025 at 0900 with Staff #9 revealed there was no documentation in Pt #35’s medical record that the legal guardian was notified of Pt #35’s injury. Interview on 01/21/2025 at 1506 with Staff #17 revealed Staff #17 did not recall notifying the legal guardian of Pt #35’s injury. Interview revealed the legal guardian should have been notified immediately after the event occurred. Staff #17 revealed the nurse was responsible for notifying the legal guardian and the notification should have been documented in a progress note. Interview on 01/24/2025 at 1300 with Staff #21 revealed Staff #21 did not notify the legal guardian of Pt #35’s injury. Interview revealed nursing staff was responsible for legal guardian notification of injuries. Staff #26 was not available for interview. 47421 4. Review of hospital policy titled “REPORTING AND INVESTIGATING PATIENT NEGLECT, ABUSE AND EXPLOITATION” last reviewed 03/31/2023 revealed, “ ...Employee Reporting Procedure ...8. In the case of a minor or adult with legal guardian, the patient’s parent or legal guardian should be notified of the incident by the appropriate personnel...” Closed medical record review of Patient #43 revealed a 16-year-old male voluntarily committed to the 1 South unit on 09/13/2024 for suicidal ideation (SI). Record review revealed a past history of anxiety and autism. Review of Provider Orders revealed the patient was admitted with self-harm precautions, suicide precautions, and Q (every) 15-minute monitoring. Review of a nursing note on 09/14/2024 at 1100 revealed “(named patient) instigated fight with peer. He was punched in the face. No safety hold, emergency meds or injuries ... Consents needed for scheduled meds. Unable to reach guardian x2 (times 2). LMVM (left message voicemail) to return call.” Review of the Discharge Summary on 09/15/2024 at 1228 revealed “ ... (named patient) was involved in multiple altercations on his first and second day on the unit at which point, father requested that (named patient) be allowed to discharge on 09/15/2024 instead of 09/16/2024 as discussed with nurse practitioner ...” Review of Authorization To Contact Family Members And Disclose Information For Treatment Purposes form revealed the patients named father and phone number was listed. Record review revealed on 09/15/2024 the patient discharged home with family. Interview on 01/15/2025 at 1100 with Staff #16 revealed that Staff #16 attempted to call the guardian but was unsuccessful and left a voicemail for the guardian to call back. Staff #16 did not recall if the patient’s guardian called back or if the guardian was informed of the incident. Interview revealed there was no documentation of when or if the guardian was informed of the altercation. 51294 5. Review on 01/10/2025 of hospital policy “Elopements: Prevention and Response,” last reviewed on 06/28/2021, revealed, “...Response to Elopement- In the event an elopement occurs, the following steps will be taken:...k. Family members/ significant others authorized by the patient’s consent to access information regarding his/her admission may be notified about the patient’s elopement and subsequent discharge.” Closed medical record review on 01/10/2025 for Patient #11 revealed a 16-year-old female admitted to the hospital on 06/24/2024 at 1124 as an IVC (Involuntary Commitment) with a diagnosis of mood lability (rapid and excessive changes in mood) with homicidal ideations (thoughts or plans to kill others). Patient #11 had a diagnosis of Disruptive Mood Dysregulation Disorder (Mood disorder characterized by anger and frequent, intense temper outbursts). Record review revealed Pt #11 had a legal guardian. Review of the Standardized Intake Assessment dated 06/24/2024 at 1200 revealed, “...Impulsive/aggressive tendencies...Patient’s Risk Summary: Patient threatening family, to kill grandparents and harm others...Demanding to leave...” High Risk Notification Alert form dated 06/24/2024 at 1215 revealed “...Elopement Risk:...Active...Physician notified 1215.” Initial nursing assessment dated 06/24/2024 at 1300 revealed, “...Arrived to unit belligerent- limited cooperation with admission process. Refused to answer many questions per report...Elopement/Aggression precautions in place. Unable to update parent at this time.” According to the Social Services Progress Note, signed 06/26/2024 at 1440) “...06/24/2024- Therapist went to the code walker admission with MHT...when code was heard over the intercom. Therapist and MHT (Mental Health Tech) went on foot trying to see if they could find the patient but the therapist did find her blue scrub top. MHT and therapist seen (sic) (Patient #11) cross the street and the RN (Registered Nurse) picked them up and they all went across the street to make sure she was safe...therapist was able to speak with (patient # 11) to keep her calm and listen to her concerns ...(Patient #11) agreed to ride with therapist...in the van back to the facility...6/25/2024...Therapist spoke with mom regarding behaviors and functioning at home.” According to Daily Nurse Progress Note dated 06/24/2024 at 1530, “ ...Admitted to unit...Unit orientation complete. Unable to speak to parent at this time.” Nursing note dated 06/24/2024 at 1930 revealed, “...Mother updated and gave consent for medication for duration of stay...” According to Daily Nurse Progress notes dated 06/26/2024 at 1132, the patient was on elopement precautions. Medical record review failed to reveal documentation of timely legal guardian notification of patient #11’s elopement. Pt #11 was discharged home on 06/27/2024. Incident report dated 06/24/2024 at 1205 (but marked as date received 06/26/2024) revealed, “...On 6/24/2024 at approximately 12:00 PM an IVC adolescent who was waiting in the intake/assessment area asked to use the restroom. The staff member allowed the patient through the locked door to use the restroom in the lobby area. During her time at the restroom, the patient pushed a staff member who was exiting the building to the floor and ran out of the facility through the front door lobby. The patient ran through the parking lot and crossed the street. Staff called 911 for assistance per policy. Staff followed the patient to maintain her safety. The patient attempted to enter the car of a passerby and staff intervened to prevent her from entering the car of a stranger. The patient began hitting and kicking staff and was placed in a hold per CPI (Crisis Prevention Institute) standards to maintain safety. Staff were able to calm the patient and then released the hold. Staff were able to talk to the patient and she agreed to return to the facility via the hospital van. Patient was returned to safety within 15 minutes of the elopement. Police were called to cancel the assistance call. The patient was admitted directly to C1 North unit (female adolescent unit) and assessed for injury...The patient’s mother was called subsequently to report the incident.” Interview on 01/13/2025 at 1700 with Staff #20 revealed that no video footage of the elopement of Patient #11 was available. Interview on 01/14/2025 at 1202 with Staff #82, when asked about documentation in the chart with reference to notification of Patient #11’s elopement they stated, “I could not find anything. I found references to talking to family but not a time.” Interview on 01/23/2025 at 1500 with Staff #47 revealed, “Two to three hours after they got her back, I asked if I needed to call the legal guardian. I was told my boss was going to handle it by the House Supervisor. I called my boss and was told they would call the parent...I don’t know who and when they called the parent.” When Staff #4 7 and the physician called the legal guardian the next day, Staff #47 explained what happened from their perspective. Staff #47 stated that the parent was “upset that they were not told, their issue was that they weren’t told timely.” Interview on 01/23/2025 at 1750 with Staff #51 revealed, “I was at the front desk, it was a real busy day, I was working alone with nine patients in the waiting area...I was busy with a patient and she (Patient #11) started running to the front door, knocked a lady down and she was out the front door. It happened so fast.” Staff #51 stated that changes have been made since the elopement and once patients come through the lobby they go back into the secured area and do not pass through the lobby to go to the bathroom. Staff #51 further stated that the sheriff will stay with them until the patient gets to the secure area in the back. Staff #51 further stated that the current practice is to have two staff members available instead of just one as had been the case on the day of the elopement. Staff # 16 who completed the initial nursing assessment was not available for an interview.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 50318 Based on hospital policy review, medical record reviews, and staff interviews, the hospital staff failed to ensure safety requirements were met by failing to remove and prevent patient access to contraband items used to perform self harm in 2 of 2 sampled patients (Pt #30, #28). The findings include: Review on 01/16/2025 of hospital policy “Contraband Search Guidelines,” last reviewed on 05/2022 revealed, “ ... All patients will have their belongings searched for potentially hazardous items by facility staff upon arrival to their assigned unit ... I. Belongings Management and Search ... 10. Items considered hazardous/contraband include, but are not limited to: ... sharp objects including scissors, knives, metal nail files, knitting needles ... all jewelry except a wedding band and watch ... any other items deemed potentially dangerous by staff ... “ 1. Closed medical record review on 01/14/2025 for Patient #30 (Pt) revealed a 14-year-old patient voluntarily admitted on 05/24/2024 for disruptive mood dysregulation (a disorder characterized with ongoing irritability, anger, and frequent, intense temper outbursts) and oppositional defiant disorder (a disorder characterized by uncooperative, defiant, and hostile behavior to authority figures). Pt #30 endorsed high risk behaviors including running away from home, was gone for eight days, and had been using marijuana. Admissions High Risk Notification Alert indicated self-harm risk with fresh cuts to Pt #30’s arm. History of Present Illness on the Nursing Assessment at 2130 revealed Pt #30 started cutting her forearms the previous week with a steak knife. Patient Contraband Search form was completed on 05/24/2024 (no time specified); the section for jewelry was marked “Yes” for a nasal piercing, with the disposition listed as “???” Initial Nursing Treatment Plan was completed at 2130 for a problem of self-injurious behavior. Interventions were listed as monitor q15 (every 15) minutes, check pt room for contraband BID (twice a day), and provide education and monitor for warning signs, effectiveness and side effects. Review of Pt #30’s orders revealed an order on 05/25/2024 for self-harm risk precautions, throughout the patient’s hospitalization. Daily Nurse Progress Note completed by Staff #45 on 06/13/2024 at 1000 revealed Staff #45 removed Pt #30’s nose piercing due to accusations by peers of Pt #30 taking it out; the septum piercing was placed in the front of the chart. Daily Nurse Progress Note completed by Staff #43 on 06/21/2024 at 1100 revealed Staff #47 saw Pt #30 exit the bathroom with fresh scratch marks that were bleeding and questioned how Pt #30 did that. Pt #30 gave Staff #47 a staple that she had taken from her phase packet. Pt #30 had bent the staple straight and was using it to self-harm. Staff #43 cleaned and bandaged the area and spoke with Pt #30 about other coping skills. Daily Nurse Progress Note on 07/02/2024 at 1000 revealed during environmental rounds, a piece of a comb was found, hidden under Pt #30’s mattress. Pt #30 was discharged home on 07/18/2024. Request for incident reports regarding Pt #30’s contraband and self-harm on 01/17/2025 revealed no incident reports had been created. Interview on 01/16/2025 at 1001 with Staff #31 revealed Pt #30’s septum piercing was not initially removed, because Pt #30 told staff it was a permanent piercing. Staff #31 revealed further discussion with a Provider should have occurred regarding the piercing. When it was determined the piercing was not permanent, it was taken out. Staff #31 revealed all piercings should be removed for the children’s campus. Staff #31 revealed the phase packet was a step program for the adolescents to work on, and in June 2024, it possibly had staples. Staff #31 revealed after this incident, they made sure there were no longer staples in the packet and only paper. Staff #31 revealed, there should be an incident report for Pt #30’s self-harm on the unit. Telephone Interview on 01/26/2025 at 1755 with Staff #43 revealed Staff #43 recalled Pt #30’s self-harm incident with the staple. Staff #43 revealed the phase packet was stapled at that time. Staff #43 talked to Pt #30, tended to her arm, and noted the scratches were not very deep. Staff #43 reported this incident to Staff #41 but did not create an incident report. Staff #43 revealed the Registered Nurses would create incident reports. Interview on 01/27/2025 at 1058 with Staff #41 revealed Staff #41 recalled Pt #30. Staff #41 confirmed the phase packets in June 2024 did have staples, and there had not been any concerns previously. Staff #41 revealed the patients were monitored with their packets in group therapy; the packets were returned at the end of the group, and the MHTs (mental health technicians) were responsible for going through the packets to ensure the packets and staples were still intact. Staff #41 revealed Pt #30’s incident occurred during group time, and the missing staple would have been noticed when the packet was turned in at the end of group. Staff #41 revealed the phase packets were loose leaf paper now. Staff #41 revealed anyone could create an incident report, which should have been created for Pt #30’s self-harm incident by the staff who found it or had the most information. Staff #41 spoke with Staff #3 and the House Supervisor but did not create an incident report for this. Staff #41 revealed the MHTs were responsible for the environmental checks, which occurred three times a day; the comb that was found most likely was from a hygiene bucket and had just been hidden as the MHTs also checked the patients’ hygiene buckets twice a day. Staff #45 no longer worked at the facility. 51294 2. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 as an IVC (Involuntary Commitment) for aggression and suicidal (thoughts to kill self) and homicidal (thoughts to hurt others) ideation with a plan. Review of the medical record revealed on “Patient Contraband Search” form that Patient #28 had a “belly ring and nose ring” that was “kept by patient”. Patient #28 was discharged on 12/14/24. Interview on 01/24/2025 at 1509 with Staff #50 in regard to piercings documented as kept by Patient #28 revealed, “It depends how fresh the piercing is, that would be a nurses decision not mine.””

“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: 26622 Based on policy and procedure review, video camera review, staffing census sheets, medical record review and staff interviews, hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19). The findings include: Review of hospital policy, “Medication Administration”, revised 05/2022, revealed “Procedure ... 20. Staff will never leave the Medication Cart or Medication Room unlocked. ...”. Review of hospital policy, “Medication Management,” revised 09/2020, revealed “Procedures for Children’s Hospital ... 5.1 The intake staff will record home medications taken into custody at the time of admissions. ... 5.2 The intake staff will place patient home medications in a tamper-resistant security bag with a copy of the inventory form attached to the outside. The bag will be sealed and taken to the unit where the patient is admitted and given to the floor nurse ... 5.3 The nurse will secure the bag in the cabinets located in the medication rooms. These cabinets are kept locked when not in use. ...” Review of hospital policy, “Medication Rooms Access and Key Control,” revised 01/2020, revealed “Policy ... implement appropriate measures to ensure only authorized individuals have access to the unit medication room. Review of hospital policy, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” revised 11/2024, revealed “Policy ... 2.0 Use of Less-Restrictive Measures: The RN and unit staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preference and information from the initial assessment prior to seclusion/restraint, including: 2.1.1 Redirecting the patient’s focus 2.1.2 Employing verbal de-escalation 2.1.3 Separating patient from group or community 2.1.4 Engaging the patient in 1:1 activity to promote safe expression of feelings 2.1.5 Offering the use of the quiet room to decrease stimuli and regain control ... 14.0 Staff Training and Competence Assessment: ... Direct care staff, NP’s (nurse practitioners), and PA’s (physician assistants) are required to attend a nationally recognized physical/aggression management training program and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment and care of a patient in restraints or seclusion. As part of orientation ...14.1 ... all direct care staff ...receive ongoing training and demonstrate an understanding of: 14.1.1 The underlying causes of threatening behaviors ... 14.1.4 Alternative techniques to redirect a patient, engage the patient in constructive discussion or activity, or otherwise help the patient maintain self-control and avert escalation. Techniques may include de-escalation, mediation, self-protection, and other non-physical techniques such as time outs. ...” Review of the hospital policy, “Code One Psychiatric Emergency” last reviewed 01/2021, revealed “Code Ones are paged to call additional staff to the area of need in order to aid in de-escalation or to assist with restrictive interventions as needed. ... Management of the Code One - Roles and Responsibilities ... The Code One Leader is the person who will oversee the crisis and give all instructions to the members of the team dealing with the out of control patient. ...” Video review on 01/08/2025 at 1445 of the incident that occurred on the adolescent female unit on 12/22/2024 revealed there were six (6) adolescent female patients that breached the nurse’s station and four (4) of the same females entered the unsecured medication room. Video review from 1830 through 2140 revealed that at 1830 Patient #5 reached over the nurse’s station and grabbed a can of ginger ale and poured the liquid onto the floor in front of the nurse’s station while Staff #10 was attempting to assist another patient with a phone call. Patient #5 gave the can to Patient #3 who drank remainder of liquids. Patient #5 reaches across nurse’s station, grabbed and turned the computer monitor screen. Patient #3 was at the nursing station counter with the can held across counter. Staff #10 remained on the telephone inside the nursing station and appeared to verbalize to Patient #5 and #3. Patient #5 took the can from Patient #3. Patient #5 paced in front of the nurse’s station with the can still in her possession. Patient #5 walked out of camera view with the can still in her hand. Staff #10 still on telephone, turned in nurse’s station with the phone receiver still in hand. Patient #3 appeared to be talking with Patient #21 who was standing behind Patient #5 and #3 near the nurse’s station. Patient #5 appeared to empty the remainder of the can and then slung the can content remainder at Staff #10 in the nurse’s station. Staff #10 remained on the telephone. 1831 Unknown patient standing at nursing station counter waiting for Staff #10 to connect phone call. Patients #21, #5, #3 and an unknown patient stood at the nurse’s station. Staff #10 gave the unknown Patient the telephone. Patient #5 continued to pace around nurse’s station with the can still in her possession. 1832 Patient #6 walked up to the nurse’s station. Staff #10 picked up cups from the floor that had been knocked off earlier by Patient #5 and placed the cups back in the same previous location between the wall and the computer at the nurse’s station. Patient #5 continued to maintain possession of the can while pacing in front of the nurse’s station. Patient #5 crushed the can and appeared to bite the can. Patient #6 appeared to get the can from Patient #5, Patient #5 shook her head as if to say no and pulled the can back. No staff were present in the nurse’s station. 1833 Staff #12 entered the nurse’s station and appeared to communicate with Patient #5. Patient #5 maintained possession of the soda can and ran towards the unit exit. Patient #5 appeared to slip in the liquid on the floor and fell. Staff #10 and Staff #11 walked to the back of the nurse’s station near the medication room and met Staff #12. 1834 Staff #11 cleaned the liquid spill from the floor with towels. Patient #5 walked through playing with the can as staff dried the floor. 1835 Staff #10 walked out of the nurse’s station but did not approach Patient #5 and then re-entered the nurse’s station. Staff #12 remained inside the nurse’s station. Patient #5 appeared at the nurse’s station with the can torn into a couple of pieces and gave Patient #3 one of the can pieces. Staff #11 re-entered the nurse’s station. Staff #10 came out of the nurse’s station. Staff #12 came out of the nurse’s station. Staff #12 opened the door to the nurse’s station, then came back out. 1836 Two nurses and one technician were on the unit near the nurse’s station. 1837 Staff #10 and Staff #12 re-entered the nurse’s station. Staff #13 entered the nurse’s station. Staff #11 re-entered the nurse’s station and Patient #20 entered the camera view and walked in front of the nurse’s station. Three nurses and two mental health technicians were in the nurse’s station. One patient was standing in front of the nurse’s station on the telephone. An unknown patient gets off the phone. Staff #14 entered from an adjoining unit. All staff were putting on gloves. Appeared a Code 1 (behavioral health emergency) was called. Staff #14 removed the walkie talkie and possibly keys and left at the nurse’s station. Other staff arrived (7 total staff - 3 nurses and 4 MHT’s) and one patient in camera view. Other patients walked down the hallway out of camera view. 1838 MHT’s from other units arrived. Staff #12 exited the nurse’s station. Two MHT’s entered the nurse’s station. MHT exits the nurse’s station. Patient #4, Patient #6, Patient #20 and an unknown patient stood at the nurse’s station. 1839 Patient #3, Patient #21, Staff #11 and Staff #13 re-entered the camera view. Patients were clapping at the return. 2 nurses and 3 mental health technicians re-entered the camera view. Patient #5 reappeared at the nurse’s station and other MHT’s gathered near the unit exit door/day room area. Staff #11 re-entered the nurse’s station. Patient #3 jumped onto the nursing station counter, laid across the counter. Patient #5 and #21 were standing at the nurse’s station. Patient #3 grabbed an I-pad from the nursing station while Staff #11 was in the nurse’s station watching. Staff #11 turned and walked away towards the medication room. Patient #3 gave the I-pad to Patient #21 who then threw the I-pad back into the nurse’s station. Patient #5 removed a medical record (patient chart) from the nurse’s station desk. Staff #11 observed the patient. Patients #5, #3 and #21 were standing in front of the nurse’s station with the medical record, then Patient #5 threw the medical record back into the nurse’s station. Patient #3 reached across the nursing station, pulled the telephone out and threw it across the nurse’s station. Staff #11 walked towards the patients, Staff #15 and Staff #10 entered the nursing station. Five other MHT’s were outside the nursing station door. Three patients were inside the nursing station with two nurses inside the nursing station and four MHT’s standing outside the nursing station. One MHT entered the nursing station. 1840 Staff #12 opened the door between the adolescent girls and children’s (littles) units to remove Patient #21 who was escalating. Staff (nurse, MHT’s) were attempting to de-escalate. The door between the units closed and Patient #21 was placed on the floor by staff. Patient #3 and #5 were pacing in front of the nurse’s station near the location where staff had Patient #21 in a hold on the floor. Staff #10 re-entered from the dayroom. Patient #3 had her hands across the nurse’s station as Patient #5 watched staff preparing to move Patient #21 to the Children’s (littles) unit (which shared the same nurse’s station). Patient #3 reached over the nurses station, picked up an I-pad and threw it at staff on the floor with Patient #21. Patient #5 was watching. Staff #16 was at the other end of the shared nurse’s station (littles) and appeared to be on the telephone. Patient #5 threw a shoe at the staff on the floor with Patient #21. Patient #5 threw a second shoe at the staff on the floor with Patient #21. Patient #3 attempted to cross over the top of the nursing station counter. MHT entered and Patient #3 retreated. 1843 Patient #5 threw shoes at a nurse near the nurse’s station. 1844 Patient #5 threw cups hitting a nurse in the head. 1846 Patient #3 threw water at a nurse. Patient #4 walked into the nurse’s station, passed directly in front of the MHT that was holding the door open. The MHT did not attempt to stop Patient #4. Patient #4 attempted to enter the medication room through a door that was propped open. Patient #4 was placed in a hold and removed from the nurse’s station. Patient #3 jumped over the nursing station counter and grabbed a telephone. Patient #20 laid across the nursing counter and attempted to grab an item from the nurse’s station. Patient #3 threw the telephone. Patient #20 was pulled from the counter by a MHT. Patient #6 removed the computer monitor from the nurse’s station and threw it to the floor. 1847 Patient #5 retrieved the phone from the nurse’s station and gave it to Patient #20. Patients #3, #6 and #4 were stomping on the computer screen that was lying on the floor. Patient #20 threw the phone on the floor. Patient #5 reached for another computer monitor in the nurse’s station. Patient #6 reached for the same computer monitor and was stopped by a nurse. Patient #4 attempted to jump over the nursing station counter, knocked an object off the desk to the floor and was stopped by the nurse and MHT. Patient #5 was slinging the phone base over the nurse’s station. Patient #6 took the phone from Patient #5 and smashed it on the floor. Patient #5 was swinging the phone receiver over the nurse’s station. Patient #3 attempted to grab the computer monitor from the nurse’s station. Patient #5 continued to swing the phone receiver over the nurse’s station. Patient #6 pulled the computer monitor from the nurse’s station. 1848 Patient #6 threw the computer monitor on the floor, then stomped on it. Patient #5 tried to pull monitor base out of the nursing desk. A nurse pulled the monitor base from Patient #5. Patient #5 was throwing the phone receiver over the nurse’s station like a lasso. Patient #3 grabbed a medical record chart from the nursing station and threw it. Patient #5 continued to twirl the phone receiver over her head. Patients #5 and #3 continued to destroy the medical record. A nurse appeared to speak with the patients in the nurse’s station while on the phone possibly calling for more assistance. 1849 Patient #5 swung the phone receiver in and out of the nurse’s station and over her head. Patient #6 threw the phone base over the nurse’s station. 1850 Patient #3 climbed over the nurse’s station, grabbed an I-pad and threw the I-pad and a walkie talkie over her shoulder. Patient #5 attempted to cross over the nurse’s station twice. Patient #5 was stopped by an MHT on her second attempt. Patient #4 jumped up on the nurse’s station counter. Patient #5 hit a MHT with the phone receiver and continued to swing the receiver over the nurse’s station. An MHT removed Patient #4 from the counter. Patient #6 threw an object at the MHT in the nurse’s station. An MHT blocked the object and then did a little dance/move. Patient #6 returned to the nurse’s station and threw a chart hitting the MHT. Patient #5 continued to swing the phone receiver over the nurse’s station at the MHT. Patients #3 and #4 jumped onto the nursing station and stood on the counter. Patient #6 swung the phone receiver and hit the MHT. Patient #5 threw an I-pad and hit the MHT. 1851 Patient #3 climbed onto the copy machine. Patient #5 climbed over the nurse’s station counter and entered the nurse’s station. Patient #4 threw a computer keyboard on the floor. Patient #6 grabbed a computer keyboard and smashed it against the nurse’s station. Patient #3 knocked out ceiling tiles and pulled metal dividers from the ceiling. A nurse removed the metal divider from Patient #3. Patient #5 stood on the nurse’s station counter. 1852 Patient #3 continued to knock out ceiling tiles. Patient #20 jumped onto the nursing station counter and sat down. Patient #21 climbed over the nurse’s from the adjoining unit. Patient #4 jumped onto the nurse’s station. Patient #3 swung from the ceiling. Patients #20, #5, and #4 sat on the counter and watched Patient #3’s attempts to climb into the ceiling. 1853 Patient #3 climbed into the ceiling and continued to knock out ceiling tiles. Patient #20 threw a chair out of the nurse’s station. An MHT stood behind the nurse’s station. Patient #21 attempted to remove a computer monitor from the adjoining nurse’s station. 1854 Patient #4 ran across the nurse’s station to the adjoining unit to assist Patient #3 in removing the computer monitor. An MHT gave Patient #5 shoes. Patient #20 gave Patient #6 a metal divider. Patient #6 hit an MHT with the metal divider. Patient #5 threw a 3-hole puncher in the air. Patient #4 stood in a rolling chair. Patient #6 entered the nurse’s station through the door (it did not appear to be locked) with a metal divider in her hand. Patient #20 threw a metal divider to Patient #5. Patient #4 threw a trashcan over the nurse’s station. Patient #20 climbed over the counter, entered the nurse’s station and tried to remove the metal monitor base. Patient #5 entered the medication room. Staff #11 appeared to try and redirect the patient. 1855 Staff #11 removed a cell phone, coat and purse and exited the medication room leaving Patient #5 in the room. Patient #21 removed a tray from a drawer in the adjoining nurse’s station and threw it. Patient #6 and #4 ran into the medication room (door propped open). Patient #6 smashed an I-pad. 1856 An MHT entered the medication room, stood holding the door open and appeared to try and redirect the patients. Patient #6 used the I-Pad to destroy the Omnicell medication cabinet screen. Patient #4 handed a cup up to Patient #3 in the ceiling. Patient #20 served drinks to the other patients. Patients #4 and #20 exited the nursing station over the counter. 1857 Patient #21 opened another drawer and threw the tray with other items from the drawer. Patient #3 fell from the ceiling onto the nurse’s station. Patient #5 attempted to break into the Omnicell with the metal divider. Patients #5 and #6 removed syringes with needles from the countertop in the medication room and opened them. Patient #6 appeared to locate a vial on the countertop and drew contents into a syringe. Patient #5 exited the medication room with two (2) syringes/needles. Patient #3 ran towards the medication room. 1858 Patient #6 walked across the medication room and withdrew water from a pitcher into the syringe. Patient #6 exited the medication room and nurse’s station with a syringe/needle and metal divider in her hand. Patient #3 entered the medication room and went behind the door out of camera view. Patient #3 left the medication room holding what appeared to be a medication bag. Patient #21 continued to throw items from the nurse’s station. 1859 Patients #20 and #3 opened the medication bag. An MHT’s entered from the adjoining unit. Patient #6 attempted to stab the MHT in the neck with the syringe/needle. An MHT placed Patient #6 in a hold and removed the syringe/needle. An MHT exited to the adjoining unit. Patient #6 re-entered the nurse’s station through the door (it did not appear to be locked). 1900 Patients #5, #21 and #20 continued to throw items from behind the nurse’s station. Patient #6 re-entered the medication room and walked behind the door out of camera view. Patient #4 returned, jumped on the nurse’s station and sat on the counter. Patient #3 came back in camera view and appeared to be holding an opened medication bottle. Patient #3 obtained a water bottle and exited the medication room. Patient #3 handed Patient #20 a water bottle and pills (unable to determine if pills were taken as back was to the camera but it did appear that the patient swallowed something). Patient #20 threw pills over the nursing station onto the unit floor in front of the nurse’s station. An MHT grabbed the metal divider from Patient #20. Patient #6 exited the medication room holding two pill bottles. Patient #3 re-entered the medication room and walked behind the door out of camera view. 1901 Nurse (from main campus) entered from the adjoining unit. Patient #21 threw charts at the nurse. Patients #3 and #21 removed soda cans from the medication room. Patient #3 exited the medication room holding approximately 4 soda cans. The medication room door was closed. An MHT (from main campus) entered the nurse’s station through the door (appeared to enter without use of a key fob/badge), Patient #21 spit soda at the MHT. The MHT removed Patients #3, #6 and #21 from the nurse’s station. 1902 An MHT and nurse placed Patient #5 in a hold on the nurse’s station counter and removed one of the two syringes/needles. Patient #3 threw an object and hit an MHT in the head. 1903 Staff continued to try and gain control over Patient #5. Patient #3 slung a phone receiver over the nurse’s station counter hitting a nurse in the face (nose). MHT’s escorted Patient #5 out of the nurse’ s station through the door. Patient #6 threw a keyboard striking an MHT. Patient #21 threw an object over the nurse’s station striking the nurse in the head. Patient #6 postured to strike an MHT with a metal divider and an MHT removed the metal divider from her hand. Patient #6 fell to the floor. An MHT attempted to redirect Patient #21 (went out of camera view). Patient #21 threw a chart and an MHT re-engaged the patient. 1905 Police arrived and placed Patients #6, #21, #5 and #4 in handcuffs. 1916 The administrator-on-call and chief nursing officer arrived. From 1920 to 2038 the police and emergency medical service were on the unit evaluating and preparing Patients #5, #21, #6, #19, #3, #20 and #4 to exit via stretcher to a local hospital for evaluation due to possible medication ingestion. 2024 The Medical Director arrived on the unit. 2140 The remaining patients were removed from the dayroom and sent to their bedrooms. Review of the C1-North (adolescent girls) unit staffing census sheets for 12/22/2024 revealed there were two (2) registered nurses and two (2) mental health technicians scheduled to work 8am-8pm and one (1) mental health technician scheduled to work 1pm to 5pm, with a census of eighteen (18) patients. There was one (1) registered nurse, who was also working as the house supervisor and two (2) mental health technicians assigned to work on the adjoining C1-West-A unit (children/littles) with a census of eleven (11) patients. Review on 01/13/2025 of the medical record for Patient #5 revealed a 15-year-old female presented via law enforcement on involuntary commitment on 12/17/2024 at 1436 with a diagnosis of suicidal ideations (plan to lay in the road to get hit by a car) and self-harm behaviors (cutting wrist with glass). Physician orders on 12/17/2024 at 1641 revealed every 15 minute observations, common area observation, self-harm risk and suicide precautions. Patient #5 had a chemical restraint documented on 12/17/2024 at 2000 for throwing items at staff, pulling the phone and computers at the nursing station and threatening staff. Physician orders on 12/18/2024 at 1052 revealed placement in a room close to the nursing station, reinforce to patient to maintain four (4) foot distance from other patients, re-education with patient on maintaining boundaries, unit restrictions and sexual aggression risk. The patient had a chemical restraint on 12/18/2024 at 1605 for altercations with peer and staff. Additional orders on 12/18/2024 at 2331 revealed elopement risk and unit restrictions. Patient #5 had a chemical restraint documented on 12/20/2024 at 1335 for attacking, yelling and spitting at staff and grabbing items in the nursing station. Physician orders on 12/20/2024 at 2342 revealed block patient room and aggression/homicide precautions. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #5 was in the dayroom and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2100. At 2106 documentation revealed that Patient #5 had been transported to the Emergency Room. Patient #5 had a physical restraint documented on 12/22/2024 at 1900 for aggression and self-harm with a syringe/needle. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #5 to an outside facility for evaluation of suspected overdose. A behavior management plan was initiated on 12/24/2024 at 1400. Patient #5 had chemical restraints for aggression, destroying property and threatening staff on 12/28/2024 at 2100, on 01/04/2025 at 1912 and on 01/05/2025 at 1520. Review of a Psychiatric Progress note documented on 01/06/2025 revealed “Pt (patient) ongoing aggression and constant conflict with peers. Pt was agitated and assaultive yesterday and required IM (intramuscular) PRN (as needed medications) due to aggression. Pt shows no improvement in mood or insight. Pt was attempting to follow staff through doors this morning. Mood ROS (Review of Systems) severe anxiety Psychosis/Mania ROS aggressive behavior required prn injection, inappropriate with peers, impulsivity. Assessment and Plan: is dangerous to self or others Patient has required or demonstrated: PRN meds in the last 24H (hours) for psychosis or aggression Self-Injury, assault, active SI/HI (suicidal/homicidal ideations) in the last 24 H.” Patient #5 was discharged to legal guardian custody on 01/06/2025. Review of incident reports for Patient #5 revealed documentation of aggression on 12/17, 12/18,12/20 (times 2), 12/21, 12/22,12/26, 12/28, 12/31/2024, 01/04 and 01/05/2025. (Total of 11 incidents between 12/17/2024 and 01/05/2025) Review on 01/23/2025 of the medical record for Patient #21 revealed a 12-year-old female presented via law enforcement on involuntary commitment on 09/27/2024 at 1850 with a diagnosis of Major Depressive disorder. Physician orders on 09/27/2024 at 2046 revealed every 15 minute observations. Physician orders written 09/27/2024 at 2207 revealed placement in room close to the nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries, aggression/homicide precaution, self-harm risk, sexual victimization risk, elopement risk and unit restriction. Review of the History and Physical documented on 09/28/2024 at 0900 revealed that Patient #21 presented with severely aggressive and assaultive behaviors. Patient #21 was transferred from the adolescent girls unit to the children’s unit on 10/08/2024 for sexual aggression. Patient #21 had a chemical restraint documented on 10/12/2024 at 1436 for assaulting peers. Physician order on 10/20/2024 at 2231 to block patient room. Review of physician orders dated 12/05/2024 at 0254 revealed place in room close to the nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries and sexual aggression risk. Review of Psychiatric Progress note documented on 12/20/2024 at 0929 revealed “Pt with ongoing mood instability and agitation and is often out of group. Pt has ongoing concerns with poor boundaries but has not had any recent aggressive incidents. Review of Psychiatric Progress note documented on 12/21/2024 at 1111 revealed “Pt states she has been feeling suicidal recently and presents depressive and anxious. Pt with active SI (suicidal ideations) this morning and states she does not want to be alive. Pt with ongoing mood instability and was self-harming per banding her head.” Patient #21 had a physical restraint documented on 12/22/2024 at 1840 for aggression/property destruction. Patient #21 had a physical restraint documented on 12/22/2024 at 1850 for aggression/property destruction. Patient #21 had a physical restraint documented on 12/22/2024 at 1902 for aggression/property destruction. Review of a Psychiatric Progress note documented on12/23/2024 at 0959 revealed documentation of Patient #21 involved in riot on the unit on 12/22/2024 and was sent out to the Emergency Department and had not returned. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #21 to an outside facility for evaluation of suspected overdose. Review of Psychiatric Progress note documented on 12/24/2024 at 0948 revealed “Pt with severe aggressive and assaultive behaviors and riotous behaviors. Pt is refusing to leave her room and is threatening to assault staff and act out again. Pt shows no improvement and has severe behavioral issues.” Patient #21 had a chemical restraint on 12/24/2024 at 1415 for self-injurious behaviors. A behavior management plan was initiated on 12/24/2024 at 1500. Physician orders documented on 12/24/2024 at 1601 revealed common area observation, suicide precautions, elopement risk and unit restriction. Review of Psychiatric Progress note documented on 12/26/2024 at 0918 revealed “Pt with severe aggressive ideations and threats towards others. Pt presents severe anxiety and suicidal ideations. Pt has no update at this time and is waiting on news for placement.” Review of Psychiatric Progress note documented on 12/27/2024 at 0938 revealed “Pt with severe aggressive ideations and threats towards others. Pt shows no improvements in mood or behaviors and is an ongoing danger towards others and self. Pt with frequent outbursts and threats towards staff.” Review of Psychiatric Progress note documented on 12/28/2024 at 0949 revealed case management reached out to group home to determine if admission arrival date was still anticipated for 01/02/2025. Review of Psychiatric Progress note documented from 12/30/2024 through 01/06/2025 revealed no change in Patient #21’s mood or behaviors. Patient #21 had a chemical restraint on 12/31/2024 at 1825 for self-injurious behaviors. Review of physician order dated 01/02/2025 revealed room monitor. Review of Psychiatric Progress note documented on 01/08/2025 revealed “ ... Pt was agitated and threatening staff yesterday and was attempting to jump the nurse’s station, throw paper, and attempts to damage property. Pt was briefly taken off the unit to seclusion and was able to calm down.” Patient #21 had a chemical restraint and seclusion on 01/10/2025 at 0935 for aggression. Patient #21 had a physical and chemical restraint on 01/14/2025 at 1245 for aggression. Patient #21 had a physical and chemical restraint on 01/14/2025 at 1316 for aggression and property damage. Patient #21 had a physical restraint on 01/16/2025 at 1430 for aggression and property damage. Review of incident reports for Patient #21 revealed documentation of aggression/self-harm on 10/09,10/12, 10/19,10/29,11/13, 11/15, 12/22,12/24/2024, 01/07 and 01/10/2025. (Total of 10 incidents between 10/09/2024 and 01/10/2025) Review on 01/14/2025 of the medical record for Patient #3 revealed a 17-year-old female presented via law enforcement on involuntary commitment on 11/16/2024 at 1926 with a diagnosis of Major Depressive Disorder, recurrent. Patient #3 was re-admitted to Hospital A on 12/24/2024 at 1505 after returning from observation admission on 12/22/2024 at Hospital B. Physician orders on 11/17/2024 at 1605 revealed every 15 minute observations ,common area observation, aggression/homicide precautions and suicide precautions. Nursing notes dated 11/27/2024 revealed that Patient #3 was agitated and aggressive to peer and staff. Patient #3 was administered Thorazine and Benadryl. Physician orders on 11/28/2024 at 0204 revealed block patient room. Physician orders dated 12/03/2024 at 1330 revealed place in room close to nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries, sexual aggression risk and sexual victimization risk. A behavior management plan was initiated on 12/03/2024 at 1200. Nursing note documented on 12/03/2024 at 2240 revealed Patient #3 was involved in altercation with another peer and that staff attempted to remove Patient #3, the patient refused. Patient #3 was involved in a physical altercation with peer on 12/15/2024. Physician orders on 12/16/2024 at 0031 revealed cheeking precautions. Patient #3 was involved in verbal and physical altercation with staff and peer on 12/16/2024. Nursing note dated 12/16/2024 at 2130 revealed that Patient #3 had obtained ink pen caps and placed in pocket. Patient #3 pulled ink pen cap out of pocket and cut her arm. Patient #3 moved to hallway, pulled a 2nd ink pen cap from her pocket making verbal threats of “stabbing” a staff member and then cut self on the neck multiple times. Staff were able to take both ink pen caps from the patient. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #3 was in the group room and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2100. At 2103 documentation revealed that Patient #3 had been transported to the Emergency Room. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. Patient #3 had chemical restraint on 12/26/2024 at 2045 for attempted elopement and aggression. Patient #3 had a chemical restraint documented on 12/29/2024 at 2025 for aggression. Patient #3 was involved in a verbal altercation on 12/30/2024 and on 12/31/2024 Patient #3 removed signs from the unit wall and was not re-directable. Late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #3 to an outside facility for evaluation of suspected overdose. Review of a Psychiatric Progress note documented on 01/02/2025 revealed “Pt (patient) is expecting to discharge today with DSS placement. Pt’s DSS and insurance are resistant to discharge due to concerns for safety. Pt is not appropriate for the milieu and is expecting to be placed by DSS today with a 2nd opinion. ... Mood ROS (Review of Systems) severe anxiety Psychosis/Mania ROS inappropriate with peers, impulsivity.” Patient #3 was discharged to legal guardian custody on 01/02/2025. Review of incident reports for Patient #3 revealed documentation of aggression/altercation on 11/17 (times 2), 11/27, 12/03, 12/15, 12/16, 12/18, 12/22,12/24 and 12/26/2024 (times 2). (Total of 10 incidents between 11/17/2024 and 12/26/2024) Review on 01/09/2025 of the medical record for Patient #6 revealed a 17-year-old female presented via law enforcement on involuntary commitment on 12/21/2024 at 1443 with a diagnosis of Major Depressive Disorder and self-harm (swallowing objects). Physician orders on 12/21/2024 at 1846 revealed every 15 minute observations, elopement risk, self-harm risk and unit restrictions. Physician orders on 12/24/2024 at 1606 revealed common area observation, aggression/homicide precautions, suicide precautions, place in room close to nursing station and unit restrictions. Physician orders dated 01/01/2025 at 2147 revealed reinforce to patient to maintain 4 foot distance from other patients, block patient room and sexual victimization risk. Patient #6 had a physical restraint documented on 12/22/2024 at 1900 for aggression and attempting to stab staff with syringe/needle. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #6 to an outside facility for evaluation of suspected overdose. A behavior management plan was initiated on 12/24/2024 at 1550. Patient #6 had chemical restraints for aggression towards staff on 01/02/2025 at 1805. Patient #6 was discharged to a group home with her legal guardian on 01/09/2025. Review of incident reports for Patient #6 revealed documentation of aggression/altercation on 12/22, 12/26/2024 and 01/02/2025. (Total of 3 incidents between 12/22/2024 and 01/02/2025) Review on 01/10/2025 of the medical record for Patient #20 revealed a 14-year-old female presented via law enforcement on involuntary commitment on 12/04/2024 at 1443 with a diagnosis of Disruptive mood disorder, aggression and suicidal ideations. Physician orders on 12/04/2024 at 1533 and 1542 revealed every 15 minute observations, place in room close to the nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries, elopement risk, self-harm risk, sexual aggression risk and unit restrictions. Physician orders on 12/05/2024 at 0237 revealed aggression/homicide precautions. Physician orders dated 12/06/2024 at 2059 revealed cheeking precautions. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1830 that Patient #20 was in the group room and calm. Further review revealed no 15 minute observation checks documented from 1830 through 2100. Patient #20 had a physical restraint documented on 12/22/2024 at 1900 for jumping over the nurse’s station to obtain contraband. At 2107 documentation revealed that Patient #20 had been transported to the Emergency Room. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #20 to an outside facility for evaluation of suspected overdose. Physician orders dated 12/23/2024 at 1833 revealed common area observation, suicide precautions, elopement risk, place in room close to nurse’s station (when available) and unit restrictions. A behavior management plan was initiated on 12/24/2024 at 1500. Review of psychiatric progress note dated 01/01/2025 at 0842 revealed “Pt expecting to discharge today and is safe to do so. Pt with ongoing mood instability and anxiety but is not an acute danger towards self. ...” Patient #20 was discharged home with mother on 01/01/2025. Review of incident reports for Patient #20 revealed documentation of aggression/self-injurious behaviors on 12/06 (times 2) and 12/22/2024. (Total of 3 incidents between 12/06/2024 and 12/22/2024) Review on 01/10/2025 of the medical record for Patient #4 revealed a 16-year-old female presented via law enforcement on involuntary commitment on 12/17/2024 at 1211 with a diagnosis of major depressive disorder, suicidal ideations and hallucinations. Review of the History and Physical documented on 12/18/2024 at 0800 revealed Patient #4 presented with reported command hallucinations “telling her to kill herself by overdose.” Patient #4 had a physical restraint documented on 12/22/2024 at 1900 for attempting to enter the medication room at 1846. Patient #4 had a physical restraint documented on 12/22/2024 at 1900 for jumping over the nurse’s station to obtain contraband at 1850. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #4 was in the group room and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2045. Observation sheet revealed other location and disruptive behavior documented at 2100. At 2106 documentation revealed that Patient #4 had been transported to the Emergency Room. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #4 to an outside facility for evaluation of suspected overdose. Review of psychiatric progress note dated 12/24/2024 at 0944 revealed Patient #4 “with severe anxiety, agitation, and aggressive behaviors. Pt shows poor insight and labile mood.” Psychiatric progress note dated 12/26/2024 at 0920 indicated that Patient #4 was experiencing auditory verbal hallucinations with severe anxiety and recent aggressive behaviors. The patient showed little improvement in mood or behaviors. Review of a psychiatric progress note dated 12/27/2024 at 0929 revealed “Pt denies suicidal or homicidal ideations. Pt denies any current safety concerns regarding personal health care post discharge. Pt has identified positive coping skills that will help pt control mood and construct positive thoughts and proactive behavior. ...” Patient #4 was discharged home with family on 12/27/2024. Review of an incident report for Patient #4 revealed documentation of aggression on 12/22/2024. Review on 01/09/2025 of the medical record for Patient #19 revealed a 14-year-old female presented on 12/17/2024 at 1813 with a diagnosis of Major Depressive Mood disorder and suicidal ideations. Documentation on 12/17/2024 at 1900 revealed that Patient #19 was a high risk for suicide and self-harm with impulsivity and aggressive tendencies. Review of the History and Physical documented on 12/18/2024 at 0800 revealed Patient #19 presented “on a voluntary hold for suicidal ideations and suicide threats made during an altercation with her mother. Mother reports that child has displayed worsening mood lability and has been making more statements that she ‘won’t be here later.’ Review of a social services progress note dated 12/19/2024 at 1045 revealed that Patient #19 was agitated and verbally aggressive. A social services progress note documented on 12/202/2024 at 1440 revealed that Patient #19 was verbally aggressive toward staff. Review of a nursing note documented on 12/20/2024 at 1740 revealed Patient #19 was involved in a verbal/physical altercation with a peer. Patient #19 was administered as needed medication and the medication was effective. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #19 was in the group room and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2100. At 2104 documentation revealed that Patient #19 had been transported to the Emergency Room. Review of psychiatric progress note dated 12/23/2024 at 1007 revealed Patient #19 had not returned from the emergency room. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #19 to an outside facility for evaluation of suspected overdose. Patient #4 was discharged home with family on 12/23/2024 after returning from the emergency room. Review of incident reports for Patient #19 revealed documentation of aggression/contraband on 12/20 and 12/22/2024. (Total of 2 incidents between 12/20/2024 and 12/22/2024) Entrance conference on 01/08/2025 at 0930 with administrative staff revealed the adolescent girls (age 12-17) unit had been changed from C1-North to the C1West-A unit and the children (littles-age 5-11) unit had been changed from C1West-A to the C1-North unit. Two (2) of the seven (7) adolescent females involved in the incident on 12/22/2024 remained in the facility and were located on the C1W-A unit. Interview on 01/21/2025 at 1450 with Staff #76 revealed Staff #76 and Staff #77 worked at Main Campus and responded to the Code One (psychiatric emergency) at the Children’s hospital together. Interview revealed there were two (2) police and a third one pulling into the parking lot when they arrived. Interview revealed that Staff #16 was at the entrance door talking with the police officers. Staff #76 indicated that they were told not to go into the unit related to a potential hostage situation. Staff #10 and a MHT were standing in the hallway outside the unit when Staff #76 and #77 arrived at the unit around 1845. Staff #77 entered the adolescent female unit and Staff #76 entered through the children’s unit. Staff #77 removed patients from the nurse’s station. Staff #76 closed the center door between the units. The patients in the TV (television) room on the children’s (littles) unit were “hysterical and crying.” Staff #14 asked Staff #76 what to do with the children (littles) and was instructed to escort the patients through the courtyard to an empty unit (West-B). Staff #76 entered the adolescent female unit through the center adjoining unit door and indicated that medical records were being thrown in and from the nurse’s station. Staff #77 was attempting to remove a syringe/needle from Patient #5’s hand and was requesting help. No staff on the unit came forward. Staff #76 assisted Staff #77 in removal of the syringe/needle from Patient #5’s hand. Staff #76 revealed “No clue where staff were that responded or were currently on the unit.” Staff #76 indicated that the patients that were not involved in the incident had “barricaded” the dayroom door. Some of the patients were in the alcove/comfort room area near the bathroom. Patient #5 ran out of the nurse’s station and had another syringe/needle in her hand. Patient #5 stood outside the comfort room near the wall and Staff #77 reacted and grabbed Patient #5’s arm to remove the syringe/needle from Patient #5’s hand. Police arrived as Patient #21 jumped Staff #77 from behind and grabbed Staff #77’s head causing the syringe/needle to fall to the floor. The interview revealed that the staff panicked. Interview revealed there were issues with nurse’s not having medication room key fobs. Staff #76 was on the unit on 12/21/2024 and stated that the house supervisor told the nurses to prop the medication room door open. Interview revealed that on 12/21/2024 on the C1-South-Adolescent male unit, the nurse had a key fob, but the key fob would not open the medication room door. Staff #76 stated that the door was propped open and was closed when not giving medications. Staff #76 revealed that the staff did not intervene early enough and should not have been behind the desk interacting with the patients. The interview revealed there was an adequate number of staff if the staff had been proactive. Staff #76 did reveal that the seclusion room was off the unit down the hallway and that there were no staff available to put a patient in seclusion. Interview revealed that Patient #5 had been causing problems for three (3) days. The interview revealed that on 12/21/2024, the nurse and MHT should have moved the patient being attacked to another unit. There was an incident on 12/20/2024 involving the same patients but they did not give the patient medications so that the patient could be discharged. Interview revealed that when the police removed the patients involved in the incident on 12/22/2024, the girls were laughing and singing Christmas carols. Interview revealed that Staff #76 was injured during the incident and required medical treatment. Interview revealed that the drawers/cabinets in the nurse’s station should be locked for safety. Staff #76 returned to work with restrictions, on 01/17/2025. Interview on 01/23/2025 at 1310 with Staff #77 revealed Staff #77 and #76 responded to the children’s hospital together. The interview revealed that when a Code One was called at the children’s hospital, the house supervisor at children’s hospital would notify the house supervisor at the Main campus. Staff #77 indicated that the main campus house supervisor would normally notify the male MHT’s working at Main campus to respond to the Code One at the children’s hospital. Staff #77 revealed that one police arrived about the same time and there were approximately six (6) other police officers at the children’s hospital entrance. Interview revealed that the plan was to try and calm the situation prior to the police going to the unit. Staff #77 entered the adolescent female unit near the dayroom. Staff #77 revealed that the patients were throwing objects, two (2) patients were coming out of the nurse’s station with pill bottles, taunting the staff. The interview revealed there was one (1) patient on the nursing station counter with two (2) syringes in hand. A second patient was walking around with a metal device in her hand. Staff #77 attempted verbal de-escalation with no avail. The interview revealed that Staff #77 analyzed the situation and how to handle who would be removed first and any threatening weapons. Staff #77 then grabbed the two (2) patients with the pill bottles and escorted them out of the nurse’s station, then spoke to and side-tracked the patient with the metal stick, removed the metal stick from the patient’s hand and then escorted the patient out of the nurse’s station. The interview revealed that Staff #77 talked with Patient #5 attempting to get the patient to give up the two (2) syringes/needles. Patient #5 was distracted by another patient, Staff #77 and #76 put the patient in a hold and removed one (1) of the syringes/needles from her hand. One of the patients outside the nursing station threw a telephone and struck Staff #76 in the face/nose. Patient #5 was escorted out of the nurses station. Patient #5 had placed the second syringe down into her shirt/bra. Interview revealed that Patient #5 was standing outside the comfort room, removed the syringe/needle from her shirt/bra and was poking the syringe/needle into her arm. Staff #77 revealed that the patient got sidetracked and looked away and Staff #77 knocked the syringe/needle out her hand. The syringe/needle fell to floor, was picked up and given to Staff #76. Staff #77 indicated that Patient #5 began kicking and fighting. Interview revealed that at the same time Patient #21 jumped Staff #77 from behind and pulled hair. The police arrived and removed Patient #21 from the area. Interview revealed that when Staff #77 arrived on the unit, the staff were huddled in the corner of the nurse’s station. Staff #77 revealed “Did expect staff to follow behind me. Talked with staff without following. I took charge of the situation.” Staff #77 had responded to two other incidents prior to the incident on 12/22/2024 and responded to multiple incidents involving Patient #5 and #21 after the 12/22/2024 incident. Interview on 01/23/2025 at 1607 with Staff #65 revealed that Staff #65 was notified by Staff #6 about the incident on 12/22/2024. Staff #65 revealed that upon arrival to the facility, the adolescent female unit was in “totally disarray.” Police and EMS had arrived at the facility. Staff #65 indicated that “pills” were found on the unit floor during clean up and given to a nurse. The interview revealed that after reviewing the video, Staff #65 identified that no one on the unit identified roles and responsibilities and no early interventions were attempted. Interview revealed that the “ringleader” should have been placed in a “standing high restrictive hold” and escorted off the unit. The interview revealed that other staff should have de-escalated and tried to control the other patients. Interview revealed that the patients should have never been left unattended and that the medication room door should have been closed “the minute the nurse’s station was compromised.” Interview revealed that most of the staff working the evening of 12/22/2024 were new and possibly did not feel confident to make decisions. Interview revealed that the Code One leader should take control and direct staff. Staff #65 revealed that Staff #74 engaged but realized no other staff engaged to help him and pulled out. Interview revealed that there was adequate staff to decrease the threat level, but staff did not use all aspects of their CPI (de-escalation) training to de-escalate the situation. Interview on 01/10/2025 at 1120 with Staff #1 revealed that the pharmacy was not notified of the medication room breach until Monday 12/23/2024. Staff #1 assessed the C1-North/C1-West-A medication room on 12/23/2024 and retrieved a plastic tray that had home medication bottles that had been picked up from the unit/unit floor after the incident. The pharmacist identified a bottle of Concerta (medication used to treat attention deficit disorder) that should have had 12 pills, only had 8 (4 pills missing) and Clozapine (antipsychotic medication used to treat schizophrenia that should have had 21 pills (all 21 were missing). Interview revealed the pharmacist did not recall receiving the medications that were found on the unit. Staff #1 indicated that the pharmacist working on 12/22/2024 made rounds on the unit and saw the medication room door propped open, shut the door and told the staff that the door could not be propped open. Interview revealed the home medications, syringes and needles should have been locked in the cabinets in the medication room and not accessible to patients. Staff #1 was made aware approximately a month ago that not all the nurse’s had medication room key fobs and that the company was not making them any longer. Interview revealed that after the incident on 12/22/2024, the facility placed key lock access on the medication room doors and key fobs were no longer required. Interview on 02/04/2025 at 1115 with Staff #78 revealed that during pharmacy rounding on 12/22/2024, the medication room door on C1-North Adolescent female unit/C1-West-A was propped open with a trashcan. Staff #78 removed the trashcan and closed the medication room door. Interview revealed there were no unit staff present to tell to keep the door closed at all times. Interview revealed that the medication room door should be locked and closed at all times. Interview of 01/21/2025 at 1010 with Staff #75 revealed that the children/littles were moved off the adjoining unit after the police arrived. Staff #75 indicated that the canned sodas were kept in a locked cabinet in the medication room for patient use. Staff #75 revealed that the cabinet in the medication room was not locked during the incident. Interview revealed that all staff except housekeeping received Crisis Prevention Intervention (CPI) training upon hire. Interview revealed that the staff were “inadequately prepared to handle the incident.” The interview revealed that the incident may have been “avoided or not gotten to where it did” if staff had intervened when Patient #5 started escalating. Interview revealed that the staff had “ample” time to close the medication room door prior to the patients breaching the medication room. Incident investigation revealed that the staff “did not initiate their appropriate CPI response training, relied on the presence of ‘large body’ to show up, and were afraid of getting fired for using wrong CPI techniques.” Interview indicated that the administrative staff guaranteed extra staff for the remainder of the week as the plan was to place the patients involved in a gown and keep them on the unit until discharge. Interview on 01/10/2025 at 1230 with Staff #6 revealed that Staff #6 was aware that approximately five (5) staff nurses did not have medication room key fobs. Staff #6 sent an email to hospital leadership about key fob concerns. Staff #6 received response that the concerns were being worked on and staff would need to share the key fobs that were available. Staff #6 received a call on 12/22/2024 from the house supervisor that there was a riot on the unit and requested permission to call the police. Staff #6 notified the Chief Nursing Officer/Chief Operating Officer. The police were at the facility when Staff #6 arrived. After the incident, staff #6 assisted with the medication room and contraband training. Interview revealed that the staff working on 12/22/2024 “did not perform what they had been trained to do and should have moved Patient #21 to a different area where the patient could not be seen or heard by the other patients involved in the incident. Interview on 01/09/2025 at 1050 with Staff #31 revealed that on the evening of 12/22/2024 the census on the adolescent female unit (C1North) was eighteen (18) with two of the 18 adolescent girls programming on the C1W-A unit bringing the census down to sixteen (16). Patient behaviors on the unit prior to the incident on 12/22/2024 were aggressive, oppositional, difficult to re-direct and personality conflicts with other patients. Interview revealed that when patients were on aggression precautions, the staff were expected to vigilantly monitor/watch the patients on the unit. Staff #31 did not recall any patients having any specific staff targets. Interview revealed that Patient #5 programmed on the C1-North unit and liked to come out of the dayroom and roam on the unit. Staff #31 was on vacation when the incident occurred and was updated and briefed about the incident upon returning. Staff #31, while on vacation, was briefed about the incident by Staff #6 and Staff #22. Staff #31 met Risk Management briefly upon return and watched the video. The interview revealed that ginger ale was used in the place of water for some of the patients. Staff #31 was not sure who used and left the soda can sitting on the nurse’s station. Interview revealed the soda can should have been discarded in the trash can in the secured medication room. Interview revealed the staff should have engaged and attempted to get the can away from the patient for safety. Interview revealed the staff attempted verbal de-escalation. The incident was “overwhelming, quite traumatic.” Interview revealed the staff had the skills and knowledge but “staff did not take the next step of CPI (Crisis Prevention Intervention).” Staff #31 did not interview the staff and/or patients involved in the incident. Code One is a psychiatric response for patient behaviors and “out of control” situations. The nurse should document the Code One in the medical record. Interview revealed that Staff #31 assisted with the immediate action plan and collected attestation education forms from the staff. Staff #31 provided verbal education on 12/27/2024 regarding medication room, contraband, pharmacy and nursing house supervisor rounding on the medication room. Interview revealed that on the evening of 12/22/2024 the medication room door was propped open due to the nurse did not have a key fob that would open the door. Staff #31 was unsure as to why the other two nurses did not assist with the key fob issue. Interview indicated that several nurses had not been given key fobs for the medication room due to there were none available in the facility. Staff #31 indicated that the company where the key fobs were purchased no longer made them. Interview revealed that Staff #31 believed the C1North unit was adequately staffed on 12/22/2024. Staff #31 indicated that when there was a staff call-out, the facility attempted via telephone calls to find staff to cover. The interview revealed that the house supervisor was pulled to staff a unit if no other coverage could be obtained. The staff were trained on Crisis Prevention Intervention (CPI) and de-escalation techniques upon hire. Staff attended hospital orientation for two (2) weeks. Week one consisted of a Human Resources day, CPI and CPR. Week two consisted of simulations, break out of staff to department specific training and the last two days (Thursday and Friday) the new hire was paired with another nurse to shadow/conduct tasks. Interview on 01/09/2025 at 1535 with Staff #12 revealed there were approximately fourteen (14) patients in the large dayroom when the event started. Staff #12 indicated that Patient #5 grabbed a soda can from the nurse’s station and ripped it apart. Staff #12 stated that Staff #13 attempted to get the can away from the patient. Staff #12 indicated that the can was hid in a bag. The nurse called for more help and “we were waiting for others to get here.” The staff tried to separate Patient #21 from the other girls. Patient #21 kicked Staff #11 in the face. Patient #21 started throwing objects from the adjoining unit (children - littles) where she had been moved. Interview revealed there were no staff on the children’s unit with Patient #21. Staff #12 stated “should have had two people to stay with Patient #21.” Interview revealed the staff should have moved Patient #5 to another location since she was the most aggressive. Staff #12 revealed there were no consequences for patients acting out. The interview revealed that there should have been more staff. The interview revealed that the medication room door was left opened because the nurses did not have key fobs for the door. Staff #12 indicated that the door to the nurse’s station was broken and was repaired the day after the incident. The interview revealed that Plexiglas was placed around the computer monitors “a couple of days ago.” Interview revealed that Patient #5 programmed and slept on the C1-North unit. Interview on 01/09/2025 at 1610 with Staff #10 revealed that on a “usual day” the patients were “pretty calm, redirectable.” On 12/22/2024, around 1430, the unit received candy/cookie bags from Santa. Shortly after the visit, the patients began to talk loudly, became volatile stating that “they should start a fight or riot.” Staff #10 reported this to the House Supervisor and indicated that more staff may be needed. The interview revealed that knowing the history of the patients, Staff #10 believed that it would take more than two (2) nurses and two (2) mental health technicians. Interview revealed that neither nurse working on the C1-North unit had medication room fobs. Staff #10 did not see Patient #5 remove the can from the nurse’s station but they did see the patient pouring the liquid from the can onto the unit floor. Staff #10 indicated that Patient #5 bragged about having the can and told staff that they “would have to fight me to get can back.” Staff #10 went out onto the floor with other staff to try and get the can. During this same time, the other patients were getting “riled up.” The staff were unable to get the can from Patient #5 and Staff #10 did not know what happened to the can. Staff #10 revealed that patients were heard saying “Can’t fight Staff #11, she’s too pretty and Staff #10 was too old.” Patient #21 was placed in a hold and moved to the “other side” (adjoining unit). Staff #10 indicated that the patients on the adjoining unit were monitored by mental health technicians and were later moved to another area. The interview revealed that the staff were behind a wall in the nursing station trying to get help. A Code One was called. The Code One would only be heard within the children’s hospital and the house supervisor would have to call via telephone over to the main campus for additional help. The house supervisor/charge nurse on C1-West-A called the police and then went to front lobby to await police arrival. Police officers were assisted to the unit when they arrived by the house supervisor. Staff #10 went to front lobby to await the arrival of other officers and was not allowed to return to the unit per the police officers. Staff #10 did not recall a nurse trying to hit the patients, “believe I was in shock.” Staff #10 recalled a mental health technician “pushed them down.” Staff #10 did not “feel” that patients were safe with the number of staff based on the patient’s acuity. The patients were aggressive and the staff feared for their own safety. Interview revealed that one nurse was struck in the face with a telephone and another nurse was hit in the side of the head with an I-pad. The interview revealed that multiple patients were discharged to decrease the census to equal the current staffing. Interview on 01/10/2025 at 1205 with Staff #13 revealed the incident began after dinner. Staff #13 stated “I don’t recall if I was on unit. I know there was a situation about a can. When I realized it, the can was ripped or something. She (patient #5) was putting it in her bra. We have to get it without being cut. I do remember saying to the nurse we got to get that. Everything happened so fast seemed like one thing after another and it got out of control fast.” Staff #13 did not know what happened to the can. “It seemed like things started happening. I did not expect that to happen that way. I was also thinking of the little kids and them crying. I do feel safety was an issue ‘at that moment. Dangerous with the can.’ Everyone’s safety, everyone was at risk at that point. I was there and I don’t remember every specific thing.” The staff were asked if they were okay and “I said I was fine.” Staff #13 stated she was “trying to take it in like this really happened. When I left I thought thank God I’m alive. Someone could have gotten seriously hurt.” The interview revealed that after the incident Staff #13 thought more communication would have helped. “If the can were communicated a little better, we could have done something else. It caught us off guard even though we work in these places.” Staff #13 indicated that looking back closer observations of the patients should have been done. “I couldn’t believe it when I hear she (patient #3) was in the ceiling, I couldn’t even believe it.” Staff #13 did not recall how many patients were on the unit and indicated that the door to the nurse’s station was not broken. The interview revealed that Staff #13 did recall the medication room door was propped open. Interview revealed that Patient #5 had been involved in incidents every day since admission (12/17/2024). Staff #13 reported to work the following day. Staff #13 revealed that there had been some changes made since the incident that included better communication and “people are moving,” Staff #13 had not noticed an increase in staff on the unit. Staff #13 indicated that if staff had been told about the patient having the can , “Maybe we could have de-escalated.” Staff #13 revealed that this interview was the first time she had talked one-on-one about the incident. Staff #13 revealed the incident was discussed in a huddle and debriefing. Interview on 01/20/2025 at 1250 with Staff #74 revealed a Code One was called and Staff #74 responded. Staff #74 was instructed to assist with separating a group of girls that were acting out. Staff #74 recalled someone mentioning a can but never did see the can. Several staff members placed Patient #21 in a hold and the other 3-4 patients stood to the side in front of the nurse’s station as if they wanted to attack the staff. The other patients started to throw objects at the staff that were trying to place Patient #21 in a hold. Interview revealed that it took six (6) staff members to place Patient #21 in a hold to move her to the adjoining unit. Interview revealed that Staff #74 attempted to block the objects that were thrown at the staff. The patients were throwing whatever they could get their hands on. Staff #74 stated “I tried to stop them from getting stuff from the nurse’s station.” The situation got progressively worse. I started getting hit with things. Interview on 01/14/2025 at 1255 with Staff #3 revealed that Staff #3 was notified about the incident by Staff #6 around 2000 on 12/22/2024. The interview revealed that Staff #3 was on the Adolescent girls unit the morning of 12/22/2024 and stated, “saw kids ramping up.” Interview revealed that per video review of the 12/22/2024 incident, the unit appeared to have had adequate staff to handle the situation, “unfortunately staff did not engage after the riot situation.” Staff #3 stated that “Staff did not do anything to stop the patients.” Staff #3 indicated that the staff needed additional training other than just Crisis Prevention Intervention. Staff #3 revealed that the facility was “hiring inexperienced staff that have never worked with mental health patients.” Interview on 01/15/2025 at 1135 with Staff #16 revealed that Staff #16 typically worked as a nurse on the unit during the week and as the house supervisor on the weekend. Interview revealed that Staff #16, more often than not, worked as a floor nurse. Interview revealed that there was a nurse call out on 12/22/2024 and no coverage could be found. Staff #16 worked as the unit nurse and the house supervisor on 12/22/2024. Staff #16 revealed that based on the acuity of the adolescent female patient, Staff #16 felt that that unit needed two nurses. Two nurses were assigned to the adolescent female unit and Staff #16 worked as the nurse on the children’s unit. Staff #16 indicated that two nurses were needed in the event that Staff #16 had to attend to house supervisor duties. The interview revealed that there were patient’s acting out on the children’s unit and one of the patients spit in Staff #50’s face. Staff #16 revealed that Staff #50 left the unit to calm down. Staff #16 told Staff #50 to go the C1-West-B unit and relieve Staff #14 and send Staff #14 to cover on C1-West-A. Staff #50 told Staff #16 “No.” Interview revealed that Staff #14 did eventually come to the C1-West-A unit but that Staff #16 did not know if Staff #50 was on the C1-West-B unit (two patients on the West-B unit). Interview revealed that Staff #10 told Staff #16 that Patient #5 had gotten a can and that they would need help. Staff #16 indicated that there was nowhere to pull staff from and that staff would only be called for an emergency. Staff #16 heard the Code One called as Staff #16 was dealing with the kids acting out on the adjoining unit. The interview revealed that the Patient #21 had been moved from the adolescent female unit to the children’s unit and was attempting to climb over the nurse’s station. Interview revealed the staff were “huddled up behind the wall in the nurse’s station.” Staff #16 attempted to talk Patient #5 into giving up the telephone she was swinging over the nurse’s station. Interview revealed “should not have been allowed to happen, staff trained.” Interview revealed that the two nurses working on the adolescent female unit did not have key fob access to the medication room and the room door was propped open. Interview on 01/17/2025 at 0935 with Staff #33 revealed that Staff #22 notified Staff #33 concerning the incident on 12/22/2024. Staff #33 responded to the facility. Staff #33 indicated there were approximately 15 police cars in the parking lot and several ambulances. The interview revealed the patients were already in transition with emergency medical services (EMS) when Staff #33 arrived on the unit. The interview revealed that Staff #33 spoke briefly with a patient that was heading out of the unit by EMS. Interview revealed that Staff #33 evaluated one (1) of the seven (7) patients that were being transferred to Hospital B prior to leaving the facility. The interview revealed that EMS assessed and evaluated the patients prior to transport. Interview revealed that none of the patient showed signs of intoxication. The interview revealed that Staff #33 communicated with the Chief Medical Officer of Psychiatry at Hospital B and provided medical information for the seven (7) adolescents. Staff #33 revealed that the parents/legal guardians of the seven (7) patients were contacted by telephone and that Staff #33 was able to reach approximately 80% of the parents/guardians. Staff #33 left voice messages for the remaining parents/guardians. The interview revealed that Staff #33 documented the parents/guardians notification in the medical record several days after the incident happened. Interview revealed that Staff #33 completed the documentation in the physician progress notes and gave to the medical records director to be placed in the medical record chart. Telephone interview on 01/17/2025 at 1525 with Staff #14 revealed a Code One was called for the C1-North unit and Staff #14 responded from the C1-West-B unit. Interview revealed there were two adolescent females from the C1-North unit programming on the C1-West-B unit when incident occurred. The interview revealed “The biggest problem was lack of leadership, no one shouting orders.” Staff #14 revealed that the patients had pulled metal strips from the ceiling and were pulling and removing contraband from the nurse’s station. Interview revealed that “(Name) made bad calls and placated the kids in front of her without considering other patients.” In summary, the hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications resulting in an unsafe environment for the delivery of care to adolescent female behavioral health patients.”

“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: 50111 Based on review of hospital policy, medical records and staff interviews, the hospital staff failed to prevent verbal abuse to patients by hospital staff for 1 of 1 sampled medical records ( Pt #52). The findings include: Review on 01/24/2025 of hospital policy “Reporting and Investigating Patient Neglect, Abuse and Exploitation,” last revised 03/31/2023, revealed, “... Patients ... are treated with dignity and respect, and have a right to be free from abuse ... 1. Abuse ... b. Engaging in unprofessional behavior (verbal or physical) that is degrading to the patient. These may include, but are not limited to, cursing, malicious teasing, baiting or humiliating the patient, obscene language or gestures, threatening remarks or gestures ...” 1. Closed medical record review on 1/21/2025 for Patient #52 (Pt) revealed a 26-year-old male admitted to the hospital on 01/05/2025 at 1649 with a diagnosis of bipolar disorder (a condition that causes extreme mood swings). Record review revealed Pt #52 was given the following medications on 01/07/2025 as a chemical restraint (medications given to control a patient’s behavior) for aggression toward peers: Ativan (a medication used to treat anxiety) 2 mg (milligrams) IM (intramuscular) at 1321, Thorazine (a medication used to treat psychosis and mental illness) 100 mg IM at 1322, and Benadryl (an antihistamine medication) 100 mg IM at 1323. Review revealed Pt #52 received further treatment and was discharged home on 01/15/2025 at 1016. Interview on 01/23/2025 at 1031 with Staff #7 revealed Pt #52 had reported to Staff #7 that hospital staff were speaking to him in a disrespectful manner. Interview revealed Staff #7 encouraged Pt #52 to report the behavior to the patient advocate or the attending physician. Interview revealed Staff #7 was not present when Pt #52 received the chemical restraint but witnessed a staff member laughing afterwards because Pt #52 was crying after receiving the IM medications. Interview revealed Staff #7 had witnessed multiple staff members cursing at patients, using a disrespectful tone toward patients, and mocking or laughing at patients. Interview revealed Staff #7 had not reported this behavior because Staff #7 feared retaliation from staff. Interview on 01/21/2025 with Staff #55 revealed Staff #55 witnessed a nurse giving medications to a patient and refusing to tell the patient what medications were being given. Staff #55 revealed that the nurse stated to the patient that “(the nurse) was the one giving the meds (medications) and the patient wouldn’t know what was given.” Staff #55 stated the behavior “evoked paranoia (distrust and suspicion of others).” Interview on 01/28/2025 at 0937 with Patient #72 revealed some of the staff talk “(expletive)” to patients. Pt #72 reported hearing “staff tell patients I don’t give a (expletive) about this job. Call the Patient Advocate. They are not going to do anything.” Interview revealed staff “argues” with the patients. Pt #72 heard staff tell patients while arguing with them, “you put your hands on me, I am going to (expletive) you up.” Pt #72 verbalized he had been hospitalized before, the current unit was the worst he had ever been on, and that no one cared how the patients were treated. Pt #72 stated there were a lot of incidents on the unit and nothing had happened. 36956 2. Interview on 01/14/2025 at 1215 with staff #56 when asked if she noticed staff disrespecting patients. Staff #56 stated “yes” and identified staff #80 as being disrespectful to patients all the time. Staff #56 witnessed staff #80 tell patients they could not have their medications because “I am on my break, don’t’ bother me” Staff #56 stated staff #80 was mean to patients. Interview on 01/14/2025 at 1237 with staff #80 revealed staff #80 worked at the facility for the last 4 years. Interview revealed that staff #80 often worked in the medication room and administered medications to patients. This surveyor asked staff #80 if staff #80 witnessed staff disrespecting patients. Staff #80 stated “I am guilty. Sometimes I am a little short with patients. I am trying to get things done.””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 40299 Based on review of policy, incident reports, and interviews with staff, hospital leadership failed to ensure adequate follow-up of adverse incidents for patient safety in 2 of 8 incidents reports reviewed (Pt #38, Pt #47). The findings include: Review of a policy on 01/27/2025 titled “Occurrence Reporting” with a revision date of 07/23, revealed “Policy: The responsibility for completing a Healthcare Peer Review (HPR) report rests with any hospital staff member who witnesses, discovers, or has direct knowledge of an occurrence. Occurrences are defined as any happening not consistent with the routine care and/or operation of the facility which may place the facility at increased risk for liability. Purpose: The Healthcare Peer Review Report is a risk management tool that notifies the hospital of potential areas of loss. It enables the hospital to take corrective action, reducing the losses and improving the quality of healthcare provided in the hospital. The HPR Report is also a reporting vehicle by which to notify Risk Management of potential liability claims. The HPR report can help the various hospital committees and administration in identifying potential areas of risk and implementing measures to reduce and prevent future claims. the overall effect is an increase in the quality of patient care provided by the hospital....11. The Risk Manager, PI Director or designee shall review the form for completeness and conduct a follow -up if appropirate....Corporate Office:...The Risk Manager will maintain summary reports of events/occurrences on a monthly basis. On a monthly basis summary reports will be forwarded to the Assistant Corporate Risk Manager no later than 10th of the following month....” 1. Review on 01/14/2025 of Patient #38 revealed a 28-year-old male admitted on 08/07/2024 under IVC for paranoia (irrational and persistent belief that others are intentionally harming, deceiving, or persecuting you) and delusions (strong, false belief someone holds onto even when there’s clear evidence showing it’s not true). Patient #38 was discharged home on 08/16/2024. Review of the incident report dated 08/10/2024 at 2045 revealed “ ... B. INCIDENT TYPE: Found in unauthorized area ...” Review revealed Staff #79 reviewed the incident report on 08/16/2024 at 0933. Interview on 01/21/2025 at 1150 with Staff #79 revealed the incident was reviewed for accuracy. Incidents at this magnitude typically only require the incident form review to ensure it was filled out correctly and if something was missing put an addendum with that information, otherwise the investigation was complete. The magnitude of the incident was based off injury and harm, and what harm was caused by the incident. Interview revealed all incidents are investigated by the Risk Manager for facts which were documented in the Midas system (incident reporting system) by the front line staff. The tabs in the Midas system gave a thorough investigation and information needed to determine incident level including level of care, day of the event, and history or intervention outcome. Interview revealed Staff #79 did not perform a video review and did not question how long Patient #38 was off the unit. Interview revealed Patient #38 was returned to the unit and was safe and was what Staff #79 was concerned with for this investigation. Interview on 01/17/2025 with Staff #22 revealed there was no video review of the incident. The only notes regarding the incident were what were provided. Interview revealed the expectation would be the staff working and involved in the incident should have been interviewed and a video review should have been conducted at the time of the investigaton. Interview on 01/21/2025 at 1707 with Staff #20 revealed the investigator did not do the expected investigation. 36956 2. Review of a closed medical record on 01/17/2025 for Patient #47 revealed a 50-year-old female admitted on 11/22/2024 via IVC (Involuntary Commitment) for SI (Suicidal Ideation). Review of the intake “High Risk Notification Alert” form dated 11/22/2024 at 1112 revealed Patient #47 had a medical diagnosis of diabetes and an allergy to Lantus Insulin (medication used to control blood sugars). Review of “Physician Medication Orders”per staff #19 revealed an order for “Insulin glargine (Lantus Insulin) Subcutaneous 100 units/ml (milliliter) SOLN (Solution) 15 units to be administered on 11/22/2024. Review of a MAR (Medication Administration Record) dated 11/22/2024 revealed the Lantus Insulin was not administered on 11/22/2024. Review of an Omnicell (medication dispenser) report for 11/22/204 revealed the Lantus Insulin was pulled out of the Omnicell but was not administered to the patient. Per investigation this surveyor was not able to confirm the Lantus Insulin was administered to Patient #47. Interview on 01/13/2025 at 1438 with Patient #47 revealed the patient alleged the patient was administered Lantus Insulin and it was documented that she had an allergy to the Insulin. Interview on 01/23/2025 at 1434 with staff #54 (Patient Advocate) revealed staff #54 was responsible for receiving and resolving patient complaints. She remembered Patient #47 made a complaint regarding an allegation that she received Lantus Insulin which she was allergic to. Staff #54 stated she “did not investigate the complaint because the complaint was turned over to Nursing and Pharmacy leadership. Staff #54 confirmed that there was not an incident report in the facility’s reporting system. Interview on 01/23/2025 at 1600 with staff #49 (Nursing Leadership) revealed staff #49 was not aware of the allegation regarding Patient #47 having received Lantus Insulin which was documented as an allergy in the patient’s medical record. Staff #49 was not aware that the medication had been removed from the Omnicell until this surveyor made staff #49 aware of the occurrence. Staff #49 confirmed there was not an investigation nor an incident report entered into the facilities incident reporting system. Staff #49 confirmed there should have been an incident report entered into the system for potential medication error. Interview with staff #88 (Pharmacist) on 01/24/2025 at 1345 revealed he made a call to staff #19 and explained the patient was allergic to Lantus Insulin and the facility did not carry Levemir Insulin that the patient stated she took at home. Interview with staff #19 on 01/25/2025 at 1052 revealed he was not aware Patient #47 had an allergy to Lantus Insulin and would not have ordered the medication for a patient with a known allergy. This surveyor requested interviews with two nurses who documented in Patient #47’s medical record regarding Lantus Insulin. Per leadership both nurses no longer worked at the facility.”

“ELIGIBILITY & PROCESS FOR APPT TO MED STAFF CFR(s): 482.22(a) The medical staff must be composed of doctors of medicine or osteopathy. In accordance with State law, including scope of practice laws, the medical staff may also include other categories of physicians (as listed at §482.12(c)(1)) and non-physician practitioners who are determined to be eligible for appointment by the governing body. This Standard is not met as evidenced by: 50318 Based on review of hospital medical staff bylaws, medical contract, credentialing file reviews, on-call schedules, and staff interviews, hospital leadership failed to ensure Advanced Practice Providers (APPs) provided age-specific care and treatment based on their delineated privileges for 4 of 4 APP credentialing files reviewed (Staff #27, Staff #28, Staff #29, Staff #4). The findings include: Review on 01/28/2025 of Medical Staff Bylaws adopted 01/29/2024 revealed, “ ... 2. To ensure the high level of professional performance of all practitioners authorized to practice in the facility, through appropriate delineation of clinical privileges that each practitioner may exercise ... Section III. Conditions and Duration of Appointment ... C. Appointment to the medical staff shall confer on the appointee only such clinical privileges as have been granted by the Governing Body in accordance with these Bylaws, and shall indicate limitations, if any, on an individual’s privileges to admit and treat patients ... Application for Appointment. A. No person shall exercise clinical privileges in the facility unless and until they apply for and receives appointment to the Medical Staff as set forth in these Bylaws ... “ Review on 01/28/2025 of Collaborative Practice Agreement, Advanced Practice Provider (APP) revealed, “ ... 3. Patient Population. The (consultation company) APP manages medical care for adults age 18 and older with a wide range of medical issues for patients requiring hospitalization for mental health conditions ...” 1. Review on 01/27/2025 of Staff #27’s credentialing file revealed, Staff #27, who was a medical Advanced Practice Provider, was initially appointed on 11/22/2022 with history and physical examination and general medical management privileges with supervision for the adult population. Staff #27 was reappointed on 11/22/2024 with full privileges for admission, history and physical examination, and general medical management for the adult population. Review revealed no privileges were granted for the adolescent or child populations. Review on 01/27/2025 of the on-call schedule from July 2024 revealed that Staff #27 was scheduled for medical consultation (consult) coverage for the adult and children’s campuses on Thursday, July 4, 2024, Saturday and Sunday, July 6 and 7, 2024, and Saturday and Sunday, July 20 and 21, 2024. Review of the on-call schedule from December 2024 revealed that Staff #27 was scheduled for medical consult coverage for the adult and children’s campuses on Sunday, December 1, 2024, and Thursday through Sunday, December 5-8, 2024. Review of the on-call schedule from January 2025 revealed that Staff #27 was scheduled for medical consult coverage for the adult and children’s campuses on Saturday and Sunday, January 11 and 12, 2025, and Saturday and Sunday, January 18 and 19, 2025. Telephone interview on 01/28/2025 at 1000 with Staff #27 revealed Staff #27 worked part-time covering medical consults and would be on-site during the day when covering consults, including the weekends. Staff #27 covered 2 weekends a month and would sometimes cover another Provider during the week. Staff #27 revealed an order would be placed for the patient who needed a consult, and the patient would typically be seen the same day. Staff #27 covered all populations/campuses (adult and children) when on-call or on-site for medical consults. Staff #27 was unsure what privileges were requested for the last reappointment and thought the privileges included adolescents, not just adults. Interview on 01/28/2025 at 1245 with Staff #32 revealed, Staff #27 was not privileged for the adolescent and child population. Staff #32 revealed, the APPs would be privileged if they continued to cover medical consults for the children’s campus. 2. Review on 01/28/2025 of Staff #28’s credentialing file revealed, Staff #28 who was an Advanced Practice Provider, was initially appointed on 05/21/2021 for history and physical examination and general medical management privileges for the adult and adolescent populations. Staff #28 was reappointed on 05/25/2023 with full privileges for history and physical examination, and general medical management for the adult and adolescent populations. Review revealed no privileges were granted for the child population. Review on 01/27/2025 of the on-call schedule from July 2024 revealed that Staff #28 was scheduled for medical consult coverage for the adult and children’s campuses on Saturday and Sunday, July 13 and 14, 2024, and Saturday and Sunday, July 27 and 28, 2024. Review of the on-call schedule from December 2024 revealed that Staff #28 was scheduled for medical consult coverage for the adult and children’s campuses on the remaining weekends in December: 14 -15, 21 -22, and 28 -29, 2024. Review of the on-call schedule from January 2025 revealed that Staff #28 was scheduled for medical consult coverage for the adult and children’s campuses on Saturday and Sunday, January 4 and 5, 2025, and Saturday and Sunday, January 25 and 26, 2025. Interview on 01/28/2025 at 1245 with Staff #32 revealed, Staff #28 was not privileged for the child population. Staff #32 revealed, they would be privileged if the APPs continued to cover medical consults for the children’s campus. 16369 3. Review on 01/27/2025 of Staff #29’s credentialing file revealed, Staff #29 who was a medical Advanced Practice Provider, was initially appointed on 05/25/2021 and granted privileges for history and physical examination and general medical management for the adult population. Staff #29 was reappointed on 05/26/2023 with full privileges for history and physical examination, and general medical management for the adult population. Review revealed no privileges were granted for the adolescent and child population. Review on 01/27/2025 of the on-call schedule from July 2024 revealed that Staff #29 was scheduled for medical consult coverage for the adult and children’s campuses on July 4, 10, 17,, 24, and 31, 2024. Interview on 01/28/2025 at 1245 with Staff #32 revealed, Staff #29 was not privileged for the adolescent and child population. Staff #32 revealed, the APPs would be privileged if they continued to cover medical consults for the children’s campus. 47421 4. Closed medical record review of Patient #43 revealed a 16-year-old male voluntarily committed to the 1 South unit on 09/13/2024 for suicidal ideation (SI). Review of Provider Orders revealed the patient was admitted under the care of Staff #4 (an APP) with self-harm precautions, suicide precautions, and Q (every) 15-minute monitoring. Review of the Discharge Summary documented by Staff #4 on 09/15/2024 at 1228 revealed “ ... (named patient) was involved in multiple altercations on his first and second day on the unit at which point, father requested that (named patient) be allowed to discharge on 09/15/2024 instead of 09/16/2024 as discussed with nurse practitioner (NP) ...” Review of the History and Physical Exam/Psychiatric Evaluation form on 09/13/2024, all medication and ancillary orders, psychiatric progress note on 09/15/2024, and Discharge Summary on 09/15/2024 revealed all were completed and signed by the Nurse Practitioner (Staff #4). Record review revealed the NP admitted and discharged the patient for psychiatric care and treatment. Record review did not reveal the patient was evaluated by a Physician during hospitalization. Interview on 01/14/2025 at 1230 with Staff #4 revealed the staff member recalled the patient. Interview revealed Staff #4 admitted the patient for psychiatric care. Interview revealed that the patient’s father was upset the patient had not been seen by a physician. Staff #4 informed the patient’s father that the patient was being seen by an NP provider. Review of a Credential file for Staff #4 revealed an approved appointment to the active medical professional staff at Facility A, effective 12/12/2023. Review of an appointment letter dated 12/12/2023 stated, “The privileges granted and maintained in your credentialing file include history and physical examination, as well as general medical management for the adult, adolescent, and children population....” Further review of Staff #4 credential file revealed a Delineation of Clinical Privileges for Facility A. Staff #4 was granted privileges by the MEC (medical executive committee) and the Board of Governors for history and physical exam and general medical management. Review did not reveal Staff #4 had psychiatric privileges. Interview on 01/28/2025 at 1245 with Staff #32 revealed, Staff #4 was privileged for history and physical examination, as well as general medical management for the adult, adolescent, and children population. Interview revelaed Staff #32 did not request and was not approved for psychiatric care and treatment for adults, adolescent and children. Interview confirmed Staff #4 had provided psychiatric care and treatment to Pt #43.”

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 16369 Based on review of Medical Stall Bylaws, credentialing files and staff interviews, the medical staff failed to conduct reappraisals of appointment and privileges granted for 2 of 6 sampled credentialing files reviewed (Staff #29, Staff #4). The findings include: Review of Medical Staff Bylaws adopted 01/29/2024 revealed, “ ... 2. To ensure the high level of professional performance of all practitioners authorized to practice in the facility, through appropriate delineation of clinical privileges that each practitioner may exercise ... Section III. Conditions and Duration of Appointment ... B. Initial medical practitioner and allied appointments shall be for a period of two (2) years which will include a provisional period of one year. Reappointments shall be for a period of two years. Any person receiving provisional appointment shall have their credentials presented to the medical staff for review prior to the end of such provisional appointment with action taken by the medical staff and Governing /body to advance the appointment to full appointment to the appropriate category, to terminate the member’s appointment at the end of the term of provisional appointment, or to extend the provisional status for purposes of obtaining other specific information. ... Application for Appointment. A. No person shall exercise clinical privileges in the facility unless and until they apply for and receives appointment to the Medical Staff as set forth in these Bylaws ... “ 1. Review on 01/27/2025 of Staff #29’s credentialing file revealed, Staff #29 who was a medical Advanced Practice Provider, was initially appointed on 05/25/2021 and granted privileges for history and physical examination and general medical management for the adult population. Review of the letter notifying Staff #29 of the appointment was dated 05/25/2021 and stated, “At the time of initial appointment, medical staff members are place on provisional status for a period of at least one year. Prior to the end of the provisional period, an evaluation of performance and recommendation for advancement to full privileges, extension of provisional status, or denial of some of or all privileges will be determined, per the Bylaws of the Medical Staff. ...” Review of the credentialing file revealed no evidence that the performance or recommendation to advance to full privileges was conducted until NP #29 was reappointed for full privileges to the adult population on May 26, 2023 (2 years after the initial appointment with provisional status). Interview on 01/29/2025 at 1125 with Staff #20 revealed there was no evidence of staff reappraisal of the provisional status for Staff #29 from 2022 through 2023. Interview revealed NP #29 had continued to work as a medical staff APP with no lapse in coverage during this time. Interview revealed Medical Staff Bylaws were not followed. 2. Review of Staff #4’s credentialing file revealed, Staff #4 who was a medical Advanced Practice Provider, was initially appointed on 12/12/2023 and granted privileges for history and physical examination and general medical management for the adult, adolescent and children population. Review of the letter notifying Staff #4 of the appointment was dated 12/12/2023 and stated, “At the time of initial appointment, medical staff members are place on provisional status for a period of at least one year. Prior to the end of the provisional period, an evaluation of performance and recommendation for advancement to full privileges, extension of provisional status, or denial of some of or all privileges will be determined, per the Bylaws of the Medical Staff. ...” Review of the credentialing file revealed no evidence that the performance or recommendation to advance to full privileges was conducted. Interview on 01/29/2025 at 1125 with Staff #20 revealed there was no evidence of staff reappraisal of the provisional status for Staff #4. Interview revealed NP #4 had continued to work as a medical staff APP with no lapse in coverage during this time. Interview revealed Medical Staff Bylaws were not followed.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 26622 Based on policy and procedure review, video camera review, staffing census sheets, medical record review and staff interviews, the hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19). The findings include: Review of hospital policy, “Medication Administration”, revised 05/2022, revealed “Procedure ... 20. Staff will never leave the Medication Cart or Medication Room unlocked. ...”. Review of hospital policy, “Medication Management,” revised 09/2020, revealed “Procedures for Children’s Hospital ... 5.1 The intake staff will record home medications taken into custody at the time of admissions. ... 5.2 The intake staff will place patient home medications in a tamper-resistant security bag with a copy of the inventory form attached to the outside. The bag will be sealed and taken to the unit where the patient is admitted and given to the floor nurse ... 5.3 The nurse will secure the bag in the cabinets located in the medication rooms. These cabinets are kept locked when not in use. ...” Review of hospital policy, “Medication Rooms Access and Key Control,” revised 01/2020, revealed “Policy ... implement appropriate measures to ensure only authorized individuals have access to the unit medication room. Review of hospital policy, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion,” revised 11/2024, revealed “Policy ... 2.0 Use of Less-Restrictive Measures: The RN and unit staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preference and information from the initial assessment prior to seclusion/restraint, including: 2.1.1 Redirecting the patient’s focus 2.1.2 Employing verbal de-escalation 2.1.3 Separating patient from group or community 2.1.4 Engaging the patient in 1:1 activity to promote safe expression of feelings 2.1.5 Offering the use of the quiet room to decrease stimuli and regain control ... 14.0 Staff Training and Competence Assessment: ... Direct care staff, NP’s (nurse practitioners), and PA’s (physician assistants) are required to attend a nationally recognized physical/aggression management training program and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment and care of a patient in restraints or seclusion. As part of orientation ...14.1 ... all direct care staff ...receive ongoing training and demonstrate an understanding of: 14.1.1 The underlying causes of threatening behaviors ... 14.1.4 Alternative techniques to redirect a patient, engage the patient in constructive discussion or activity, or otherwise help the patient maintain self-control and avert escalation. Techniques may include de-escalation, mediation, self-protection, and other non-physical techniques such as time outs. ...” Review of the hospital policy, “Code One Psychiatric Emergency” last reviewed 01/2021, revealed “Code Ones are paged to call additional staff to the area of need in order to aid in de-escalation or to assist with restrictive interventions as needed. ... Management of the Code One - Roles and Responsibilities ... The Code One Leader is the person who will oversee the crisis and give all instructions to the members of the team dealing with the out of control patient. ...” Video review on 01/08/2025 at 1445 of the incident that occurred on the adolescent female unit on 12/22/2024 revealed there were six (6) adolescent female patients that breached the nurse’s station and four (4) of the same females entered the unsecured medication room. Video review from 1830 through 2140 revealed that at 1830 Patient #5 reached over the nurse’s station and grabbed a can of ginger ale and poured the liquid onto the floor in front of the nurse’s station while Staff #10 was attempting to assist another patient with a phone call. Patient #5 gave the can to Patient #3 who drank remainder of liquids. Patient #5 reaches across nurse’s station, grabbed and turned the computer monitor screen. Patient #3 was at the nursing station counter with the can held across counter. Staff #10 remained on the telephone inside the nursing station and appeared to verbalize to Patient #5 and #3. Patient #5 took the can from Patient #3. Patient #5 paced in front of the nurse’s station with the can still in her possession. Patient #5 walked out of camera view with the can still in her hand. Staff #10 still on telephone, turned in nurse’s station with the phone receiver still in hand. Patient #3 appeared to be talking with Patient #21 who was standing behind Patient #5 and #3 near the nurse’s station. Patient #5 appeared to empty the remainder of the can and then slung the can content remainder at Staff #10 in the nurse’s station. Staff #10 remained on the telephone. 1831 Unknown patient standing at nursing station counter waiting for Staff #10 to connect phone call. Patients #21, #5, #3 and an unknown patient stood at the nurse’s station. Staff #10 gave the unknown Patient the telephone. Patient #5 continued to pace around nurse’s station with the can still in her possession. 1832 Patient #6 walked up to the nurse’s station. Staff #10 picked up cups from the floor that had been knocked off earlier by Patient #5 and placed the cups back in the same previous location between the wall and the computer at the nurse’s station. Patient #5 continued to maintain possession of the can while pacing in front of the nurse’s station. Patient #5 crushed the can and appeared to bite the can. Patient #6 appeared to get the can from Patient #5, Patient #5 shook her head as if to say no and pulled the can back. No staff were present in the nurse’s station. 1833 Staff #12 entered the nurse’s station and appeared to communicate with Patient #5. Patient #5 maintained possession of the soda can and ran towards the unit exit. Patient #5 appeared to slip in the liquid on the floor and fell. Staff #10 and Staff #11 walked to the back of the nurse’s station near the medication room and met Staff #12. 1834 Staff #11 cleaned the liquid spill from the floor with towels. Patient #5 walked through playing with the can as staff dried the floor. 1835 Staff #10 walked out of the nurse’s station but did not approach Patient #5 and then re-entered the nurse’s station. Staff #12 remained inside the nurse’s station. Patient #5 appeared at the nurse’s station with the can torn into a couple of pieces and gave Patient #3 one of the can pieces. Staff #11 re-entered the nurse’s station. Staff #10 came out of the nurse’s station. Staff #12 came out of the nurse’s station. Staff #12 opened the door to the nurse’s station, then came back out. 1836 Two nurses and one technician were on the unit near the nurse’s station. 1837 Staff #10 and Staff #12 re-entered the nurse’s station. Staff #13 entered the nurse’s station. Staff #11 re-entered the nurse’s station and Patient #20 entered the camera view and walked in front of the nurse’s station. Three nurses and two mental health technicians were in the nurse’s station. One patient was standing in front of the nurse’s station on the telephone. An unknown patient gets off the phone. Staff #14 entered from an adjoining unit. All staff were putting on gloves. Appeared a Code 1 (behavioral health emergency) was called. Staff #14 removed the walkie talkie and possibly keys and left at the nurse’s station. Other staff arrived (7 total staff - 3 nurses and 4 MHT’s) and one patient in camera view. Other patients walked down the hallway out of camera view. 1838 MHT’s from other units arrived. Staff #12 exited the nurse’s station. Two MHT’s entered the nurse’s station. MHT exits the nurse’s station. Patient #4, Patient #6, Patient #20 and an unknown patient stood at the nurse’s station. 1839 Patient #3, Patient #21, Staff #11 and Staff #13 re-entered the camera view. Patients were clapping at the return. 2 nurses and 3 mental health technicians re-entered the camera view. Patient #5 reappeared at the nurse’s station and other MHT’s gathered near the unit exit door/day room area. Staff #11 re-entered the nurse’s station. Patient #3 jumped onto the nursing station counter, laid across the counter. Patient #5 and #21 were standing at the nurse’s station. Patient #3 grabbed an I-pad from the nursing station while Staff #11 was in the nurse’s station watching. Staff #11 turned and walked away towards the medication room. Patient #3 gave the I-pad to Patient #21 who then threw the I-pad back into the nurse’s station. Patient #5 removed a medical record (patient chart) from the nurse’s station desk. Staff #11 observed the patient. Patients #5, #3 and #21 were standing in front of the nurse’s station with the medical record, then Patient #5 threw the medical record back into the nurse’s station. Patient #3 reached across the nursing station, pulled the telephone out and threw it across the nurse’s station. Staff #11 walked towards the patients, Staff #15 and Staff #10 entered the nursing station. Five other MHT’s were outside the nursing station door. Three patients were inside the nursing station with two nurses inside the nursing station and four MHT’s standing outside the nursing station. One MHT entered the nursing station. 1840 Staff #12 opened the door between the adolescent girls and children’s (littles) units to remove Patient #21 who was escalating. Staff (nurse, MHT’s) were attempting to de-escalate. The door between the units closed and Patient #21 was placed on the floor by staff. Patient #3 and #5 were pacing in front of the nurse’s station near the location where staff had Patient #21 in a hold on the floor. Staff #10 re-entered from the dayroom. Patient #3 had her hands across the nurse’s station as Patient #5 watched staff preparing to move Patient #21 to the Children’s (littles) unit (which shared the same nurse’s station). Patient #3 reached over the nurses station, picked up an I-pad and threw it at staff on the floor with Patient #21. Patient #5 was watching. Staff #16 was at the other end of the shared nurse’s station (littles) and appeared to be on the telephone. Patient #5 threw a shoe at the staff on the floor with Patient #21. Patient #5 threw a second shoe at the staff on the floor with Patient #21. Patient #3 attempted to cross over the top of the nursing station counter. MHT entered and Patient #3 retreated. 1843 Patient #5 threw shoes at a nurse near the nurse’s station. 1844 Patient #5 threw cups hitting a nurse in the head. 1846 Patient #3 threw water at a nurse. Patient #4 walked into the nurse’s station, passed directly in front of the MHT that was holding the door open. The MHT did not attempt to stop Patient #4. Patient #4 attempted to enter the medication room through a door that was propped open. Patient #4 was placed in a hold and removed from the nurse’s station. Patient #3 jumped over the nursing station counter and grabbed a telephone. Patient #20 laid across the nursing counter and attempted to grab an item from the nurse’s station. Patient #3 threw the telephone. Patient #20 was pulled from the counter by a MHT. Patient #6 removed the computer monitor from the nurse’s station and threw it to the floor. 1847 Patient #5 retrieved the phone from the nurse’s station and gave it to Patient #20. Patients #3, #6 and #4 were stomping on the computer screen that was lying on the floor. Patient #20 threw the phone on the floor. Patient #5 reached for another computer monitor in the nurse’s station. Patient #6 reached for the same computer monitor and was stopped by a nurse. Patient #4 attempted to jump over the nursing station counter, knocked an object off the desk to the floor and was stopped by the nurse and MHT. Patient #5 was slinging the phone base over the nurse’s station. Patient #6 took the phone from Patient #5 and smashed it on the floor. Patient #5 was swinging the phone receiver over the nurse’s station. Patient #3 attempted to grab the computer monitor from the nurse’s station. Patient #5 continued to swing the phone receiver over the nurse’s station. Patient #6 pulled the computer monitor from the nurse’s station. 1848 Patient #6 threw the computer monitor on the floor, then stomped on it. Patient #5 tried to pull monitor base out of the nursing desk. A nurse pulled the monitor base from Patient #5. Patient #5 was throwing the phone receiver over the nurse’s station like a lasso. Patient #3 grabbed a medical record chart from the nursing station and threw it. Patient #5 continued to twirl the phone receiver over her head. Patients #5 and #3 continued to destroy the medical record. A nurse appeared to speak with the patients in the nurse’s station while on the phone possibly calling for more assistance. 1849 Patient #5 swung the phone receiver in and out of the nurse’s station and over her head. Patient #6 threw the phone base over the nurse’s station. 1850 Patient #3 climbed over the nurse’s station, grabbed an I-pad and threw the I-pad and a walkie talkie over her shoulder. Patient #5 attempted to cross over the nurse’s station twice. Patient #5 was stopped by an MHT on her second attempt. Patient #4 jumped up on the nurse’s station counter. Patient #5 hit a MHT with the phone receiver and continued to swing the receiver over the nurse’s station. An MHT removed Patient #4 from the counter. Patient #6 threw an object at the MHT in the nurse’s station. An MHT blocked the object and then did a little dance/move. Patient #6 returned to the nurse’s station and threw a chart hitting the MHT. Patient #5 continued to swing the phone receiver over the nurse’s station at the MHT. Patients #3 and #4 jumped onto the nursing station and stood on the counter. Patient #6 swung the phone receiver and hit the MHT. Patient #5 threw an I-pad and hit the MHT. 1851 Patient #3 climbed onto the copy machine. Patient #5 climbed over the nurse’s station counter and entered the nurse’s station. Patient #4 threw a computer keyboard on the floor. Patient #6 grabbed a computer keyboard and smashed it against the nurse’s station. Patient #3 knocked out ceiling tiles and pulled metal dividers from the ceiling. A nurse removed the metal divider from Patient #3. Patient #5 stood on the nurse’s station counter. 1852 Patient #3 continued to knock out ceiling tiles. Patient #20 jumped onto the nursing station counter and sat down. Patient #21 climbed over the nurse’s from the adjoining unit. Patient #4 jumped onto the nurse’s station. Patient #3 swung from the ceiling. Patients #20, #5, and #4 sat on the counter and watched Patient #3’s attempts to climb into the ceiling. 1853 Patient #3 climbed into the ceiling and continued to knock out ceiling tiles. Patient #20 threw a chair out of the nurse’s station. An MHT stood behind the nurse’s station. Patient #21 attempted to remove a computer monitor from the adjoining nurse’s station. 1854 Patient #4 ran across the nurse’s station to the adjoining unit to assist Patient #3 in removing the computer monitor. An MHT gave Patient #5 shoes. Patient #20 gave Patient #6 a metal divider. Patient #6 hit an MHT with the metal divider. Patient #5 threw a 3-hole puncher in the air. Patient #4 stood in a rolling chair. Patient #6 entered the nurse’s station through the door (it did not appear to be locked) with a metal divider in her hand. Patient #20 threw a metal divider to Patient #5. Patient #4 threw a trashcan over the nurse’s station. Patient #20 climbed over the counter, entered the nurse’s station and tried to remove the metal monitor base. Patient #5 entered the medication room. Staff #11 appeared to try and redirect the patient. 1855 Staff #11 removed a cell phone, coat and purse and exited the medication room leaving Patient #5 in the room. Patient #21 removed a tray from a drawer in the adjoining nurse’s station and threw it. Patient #6 and #4 ran into the medication room (door propped open). Patient #6 smashed an I-pad. 1856 An MHT entered the medication room, stood holding the door open and appeared to try and redirect the patients. Patient #6 used the I-Pad to destroy the Omnicell medication cabinet screen. Patient #4 handed a cup up to Patient #3 in the ceiling. Patient #20 served drinks to the other patients. Patients #4 and #20 exited the nursing station over the counter. 1857 Patient #21 opened another drawer and threw the tray with other items from the drawer. Patient #3 fell from the ceiling onto the nurse’s station. Patient #5 attempted to break into the Omnicell with the metal divider. Patients #5 and #6 removed syringes with needles from the countertop in the medication room and opened them. Patient #6 appeared to locate a vial on the countertop and drew contents into a syringe. Patient #5 exited the medication room with two (2) syringes/needles. Patient #3 ran towards the medication room. 1858 Patient #6 walked across the medication room and withdrew water from a pitcher into the syringe. Patient #6 exited the medication room and nurse’s station with a syringe/needle and metal divider in her hand. Patient #3 entered the medication room and went behind the door out of camera view. Patient #3 left the medication room holding what appeared to be a medication bag. Patient #21 continued to throw items from the nurse’s station. 1859 Patients #20 and #3 opened the medication bag. An MHT’s entered from the adjoining unit. Patient #6 attempted to stab the MHT in the neck with the syringe/needle. An MHT placed Patient #6 in a hold and removed the syringe/needle. An MHT exited to the adjoining unit. Patient #6 re-entered the nurse’s station through the door (it did not appear to be locked). 1900 Patients #5, #21 and #20 continued to throw items from behind the nurse’s station. Patient #6 re-entered the medication room and walked behind the door out of camera view. Patient #4 returned, jumped on the nurse’s station and sat on the counter. Patient #3 came back in camera view and appeared to be holding an opened medication bottle. Patient #3 obtained a water bottle and exited the medication room. Patient #3 handed Patient #20 a water bottle and pills (unable to determine if pills were taken as back was to the camera but it did appear that the patient swallowed something). Patient #20 threw pills over the nursing station onto the unit floor in front of the nurse’s station. An MHT grabbed the metal divider from Patient #20. Patient #6 exited the medication room holding two pill bottles. Patient #3 re-entered the medication room and walked behind the door out of camera view. 1901 Nurse (from main campus) entered from the adjoining unit. Patient #21 threw charts at the nurse. Patients #3 and #21 removed soda cans from the medication room. Patient #3 exited the medication room holding approximately 4 soda cans. The medication room door was closed. An MHT (from main campus) entered the nurse’s station through the door (appeared to enter without use of a key fob/badge), Patient #21 spit soda at the MHT. The MHT removed Patients #3, #6 and #21 from the nurse’s station. 1902 An MHT and nurse placed Patient #5 in a hold on the nurse’s station counter and removed one of the two syringes/needles. Patient #3 threw an object and hit an MHT in the head. 1903 Staff continued to try and gain control over Patient #5. Patient #3 slung a phone receiver over the nurse’s station counter hitting a nurse in the face (nose). MHT’s escorted Patient #5 out of the nurse’ s station through the door. Patient #6 threw a keyboard striking an MHT. Patient #21 threw an object over the nurse’s station striking the nurse in the head. Patient #6 postured to strike an MHT with a metal divider and an MHT removed the metal divider from her hand. Patient #6 fell to the floor. An MHT attempted to redirect Patient #21 (went out of camera view). Patient #21 threw a chart and an MHT re-engaged the patient. 1905 Police arrived and placed Patients #6, #21, #5 and #4 in handcuffs. 1916 The administrator-on-call and chief nursing officer arrived. From 1920 to 2038 the police and emergency medical service were on the unit evaluating and preparing Patients #5, #21, #6, #19, #3, #20 and #4 to exit via stretcher to a local hospital for evaluation due to possible medication ingestion. 2024 The Medical Director arrived on the unit. 2140 The remaining patients were removed from the dayroom and sent to their bedrooms. Review of the C1-North (adolescent girls) unit staffing census sheets for 12/22/2024 revealed there were two (2) registered nurses and two (2) mental health technicians scheduled to work 8am-8pm and one (1) mental health technician scheduled to work 1pm to 5pm, with a census of eighteen (18) patients. There was one (1) registered nurse, who was also working as the house supervisor and two (2) mental health technicians assigned to work on the adjoining C1-West-A unit (children/littles) with a census of eleven (11) patients. Review on 01/13/2025 of the medical record for Patient #5 revealed a 15-year-old female presented via law enforcement on involuntary commitment on 12/17/2024 at 1436 with a diagnosis of suicidal ideations (plan to lay in the road to get hit by a car) and self-harm behaviors (cutting wrist with glass). Physician orders on 12/17/2024 at 1641 revealed every 15 minute observations, common area observation, self-harm risk and suicide precautions. Patient #5 had a chemical restraint documented on 12/17/2024 at 2000 for throwing items at staff, pulling the phone and computers at the nursing station and threatening staff. Physician orders on 12/18/2024 at 1052 revealed placement in a room close to the nursing station, reinforce to patient to maintain four (4) foot distance from other patients, re-education with patient on maintaining boundaries, unit restrictions and sexual aggression risk. The patient had a chemical restraint on 12/18/2024 at 1605 for altercations with peer and staff. Additional orders on 12/18/2024 at 2331 revealed elopement risk and unit restrictions. Patient #5 had a chemical restraint documented on 12/20/2024 at 1335 for attacking, yelling and spitting at staff and grabbing items in the nursing station. Physician orders on 12/20/2024 at 2342 revealed block patient room and aggression/homicide precautions. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #5 was in the dayroom and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2100. At 2106 documentation revealed that Patient #5 had been transported to the Emergency Room. Patient #5 had a physical restraint documented on 12/22/2024 at 1900 for aggression and self-harm with a syringe/needle. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #5 to an outside facility for evaluation of suspected overdose. A behavior management plan was initiated on 12/24/2024 at 1400. Patient #5 had chemical restraints for aggression, destroying property and threatening staff on 12/28/2024 at 2100, on 01/04/2025 at 1912 and on 01/05/2025 at 1520. Review of a Psychiatric Progress note documented on 01/06/2025 revealed “Pt (patient) ongoing aggression and constant conflict with peers. Pt was agitated and assaultive yesterday and required IM (intramuscular) PRN (as needed medications) due to aggression. Pt shows no improvement in mood or insight. Pt was attempting to follow staff through doors this morning. Mood ROS (Review of Systems) severe anxiety Psychosis/Mania ROS aggressive behavior required prn injection, inappropriate with peers, impulsivity. Assessment and Plan: is dangerous to self or others Patient has required or demonstrated: PRN meds in the last 24H (hours) for psychosis or aggression Self-Injury, assault, active SI/HI (suicidal/homicidal ideations) in the last 24 H.” Patient #5 was discharged to legal guardian custody on 01/06/2025. Review of incident reports for Patient #5 revealed documentation of aggression on 12/17, 12/18,12/20 (times 2), 12/21, 12/22,12/26, 12/28, 12/31/2024, 01/04 and 01/05/2025. (Total of 11 incidents between 12/17/2024 and 01/05/2025) Review on 01/23/2025 of the medical record for Patient #21 revealed a 12-year-old female presented via law enforcement on involuntary commitment on 09/27/2024 at 1850 with a diagnosis of Major Depressive disorder. Physician orders on 09/27/2024 at 2046 revealed every 15 minute observations. Physician orders written 09/27/2024 at 2207 revealed placement in room close to the nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries, aggression/homicide precaution, self-harm risk, sexual victimization risk, elopement risk and unit restriction. Review of the History and Physical documented on 09/28/2024 at 0900 revealed that Patient #21 presented with severely aggressive and assaultive behaviors. Patient #21 was transferred from the adolescent girls unit to the children’s unit on 10/08/2024 for sexual aggression. Patient #21 had a chemical restraint documented on 10/12/2024 at 1436 for assaulting peers. Physician order on 10/20/2024 at 2231 to block patient room. Review of physician orders dated 12/05/2024 at 0254 revealed place in room close to the nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries and sexual aggression risk. Review of Psychiatric Progress note documented on 12/20/2024 at 0929 revealed “Pt with ongoing mood instability and agitation and is often out of group. Pt has ongoing concerns with poor boundaries but has not had any recent aggressive incidents. Review of Psychiatric Progress note documented on 12/21/2024 at 1111 revealed “Pt states she has been feeling suicidal recently and presents depressive and anxious. Pt with active SI (suicidal ideations) this morning and states she does not want to be alive. Pt with ongoing mood instability and was self-harming per banding her head.” Patient #21 had a physical restraint documented on 12/22/2024 at 1840 for aggression/property destruction. Patient #21 had a physical restraint documented on 12/22/2024 at 1850 for aggression/property destruction. Patient #21 had a physical restraint documented on 12/22/2024 at 1902 for aggression/property destruction. Review of a Psychiatric Progress note documented on12/23/2024 at 0959 revealed documentation of Patient #21 involved in riot on the unit on 12/22/2024 and was sent out to the Emergency Department and had not returned. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #21 to an outside facility for evaluation of suspected overdose. Review of Psychiatric Progress note documented on 12/24/2024 at 0948 revealed “Pt with severe aggressive and assaultive behaviors and riotous behaviors. Pt is refusing to leave her room and is threatening to assault staff and act out again. Pt shows no improvement and has severe behavioral issues.” Patient #21 had a chemical restraint on 12/24/2024 at 1415 for self-injurious behaviors. A behavior management plan was initiated on 12/24/2024 at 1500. Physician orders documented on 12/24/2024 at 1601 revealed common area observation, suicide precautions, elopement risk and unit restriction. Review of Psychiatric Progress note documented on 12/26/2024 at 0918 revealed “Pt with severe aggressive ideations and threats towards others. Pt presents severe anxiety and suicidal ideations. Pt has no update at this time and is waiting on news for placement.” Review of Psychiatric Progress note documented on 12/27/2024 at 0938 revealed “Pt with severe aggressive ideations and threats towards others. Pt shows no improvements in mood or behaviors and is an ongoing danger towards others and self. Pt with frequent outbursts and threats towards staff.” Review of Psychiatric Progress note documented on 12/28/2024 at 0949 revealed case management reached out to group home to determine if admission arrival date was still anticipated for 01/02/2025. Review of Psychiatric Progress note documented from 12/30/2024 through 01/06/2025 revealed no change in Patient #21’s mood or behaviors. Patient #21 had a chemical restraint on 12/31/2024 at 1825 for self-injurious behaviors. Review of physician order dated 01/02/2025 revealed room monitor. Review of Psychiatric Progress note documented on 01/08/2025 revealed “ ... Pt was agitated and threatening staff yesterday and was attempting to jump the nurse’s station, throw paper, and attempts to damage property. Pt was briefly taken off the unit to seclusion and was able to calm down.” Patient #21 had a chemical restraint and seclusion on 01/10/2025 at 0935 for aggression. Patient #21 had a physical and chemical restraint on 01/14/2025 at 1245 for aggression. Patient #21 had a physical and chemical restraint on 01/14/2025 at 1316 for aggression and property damage. Patient #21 had a physical restraint on 01/16/2025 at 1430 for aggression and property damage. Review of incident reports for Patient #21 revealed documentation of aggression/self-harm on 10/09,10/12, 10/19,10/29,11/13, 11/15, 12/22,12/24/2024, 01/07 and 01/10/2025. (Total of 10 incidents between 10/09/2024 and 01/10/2025) Review on 01/14/2025 of the medical record for Patient #3 revealed a 17-year-old female presented via law enforcement on involuntary commitment on 11/16/2024 at 1926 with a diagnosis of Major Depressive Disorder, recurrent. Patient #3 was re-admitted to Hospital A on 12/24/2024 at 1505 after returning from observation admission on 12/22/2024 at Hospital B. Physician orders on 11/17/2024 at 1605 revealed every 15 minute observations ,common area observation, aggression/homicide precautions and suicide precautions. Nursing notes dated 11/27/2024 revealed that Patient #3 was agitated and aggressive to peer and staff. Patient #3 was administered Thorazine and Benadryl. Physician orders on 11/28/2024 at 0204 revealed block patient room. Physician orders dated 12/03/2024 at 1330 revealed place in room close to nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries, sexual aggression risk and sexual victimization risk. A behavior management plan was initiated on 12/03/2024 at 1200. Nursing note documented on 12/03/2024 at 2240 revealed Patient #3 was involved in altercation with another peer and that staff attempted to remove Patient #3, the patient refused. Patient #3 was involved in a physical altercation with peer on 12/15/2024. Physician orders on 12/16/2024 at 0031 revealed cheeking precautions. Patient #3 was involved in verbal and physical altercation with staff and peer on 12/16/2024. Nursing note dated 12/16/2024 at 2130 revealed that Patient #3 had obtained ink pen caps and placed in pocket. Patient #3 pulled ink pen cap out of pocket and cut her arm. Patient #3 moved to hallway, pulled a 2nd ink pen cap from her pocket making verbal threats of “stabbing” a staff member and then cut self on the neck multiple times. Staff were able to take both ink pen caps from the patient. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #3 was in the group room and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2100. At 2103 documentation revealed that Patient #3 had been transported to the Emergency Room. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. Patient #3 had chemical restraint on 12/26/2024 at 2045 for attempted elopement and aggression. Patient #3 had a chemical restraint documented on 12/29/2024 at 2025 for aggression. Patient #3 was involved in a verbal altercation on 12/30/2024 and on 12/31/2024 Patient #3 removed signs from the unit wall and was not re-directable. Late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #3 to an outside facility for evaluation of suspected overdose. Review of a Psychiatric Progress note documented on 01/02/2025 revealed “Pt (patient) is expecting to discharge today with DSS placement. Pt’s DSS and insurance are resistant to discharge due to concerns for safety. Pt is not appropriate for the milieu and is expecting to be placed by DSS today with a 2nd opinion. ... Mood ROS (Review of Systems) severe anxiety Psychosis/Mania ROS inappropriate with peers, impulsivity.” Patient #3 was discharged to legal guardian custody on 01/02/2025. Review of incident reports for Patient #3 revealed documentation of aggression/altercation on 11/17 (times 2), 11/27, 12/03, 12/15, 12/16, 12/18, 12/22,12/24 and 12/26/2024 (times 2). (Total of 10 incidents between 11/17/2024 and 12/26/2024) Review on 01/09/2025 of the medical record for Patient #6 revealed a 17-year-old female presented via law enforcement on involuntary commitment on 12/21/2024 at 1443 with a diagnosis of Major Depressive Disorder and self-harm (swallowing objects). Physician orders on 12/21/2024 at 1846 revealed every 15 minute observations, elopement risk, self-harm risk and unit restrictions. Physician orders on 12/24/2024 at 1606 revealed common area observation, aggression/homicide precautions, suicide precautions, place in room close to nursing station and unit restrictions. Physician orders dated 01/01/2025 at 2147 revealed reinforce to patient to maintain 4 foot distance from other patients, block patient room and sexual victimization risk. Patient #6 had a physical restraint documented on 12/22/2024 at 1900 for aggression and attempting to stab staff with syringe/needle. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #6 to an outside facility for evaluation of suspected overdose. A behavior management plan was initiated on 12/24/2024 at 1550. Patient #6 had chemical restraints for aggression towards staff on 01/02/2025 at 1805. Patient #6 was discharged to a group home with her legal guardian on 01/09/2025. Review of incident reports for Patient #6 revealed documentation of aggression/altercation on 12/22, 12/26/2024 and 01/02/2025. (Total of 3 incidents between 12/22/2024 and 01/02/2025) Review on 01/10/2025 of the medical record for Patient #20 revealed a 14-year-old female presented via law enforcement on involuntary commitment on 12/04/2024 at 1443 with a diagnosis of Disruptive mood disorder, aggression and suicidal ideations. Physician orders on 12/04/2024 at 1533 and 1542 revealed every 15 minute observations, place in room close to the nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries, elopement risk, self-harm risk, sexual aggression risk and unit restrictions. Physician orders on 12/05/2024 at 0237 revealed aggression/homicide precautions. Physician orders dated 12/06/2024 at 2059 revealed cheeking precautions. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1830 that Patient #20 was in the group room and calm. Further review revealed no 15 minute observation checks documented from 1830 through 2100. Patient #20 had a physical restraint documented on 12/22/2024 at 1900 for jumping over the nurse’s station to obtain contraband. At 2107 documentation revealed that Patient #20 had been transported to the Emergency Room. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #20 to an outside facility for evaluation of suspected overdose. Physician orders dated 12/23/2024 at 1833 revealed common area observation, suicide precautions, elopement risk, place in room close to nurse’s station (when available) and unit restrictions. A behavior management plan was initiated on 12/24/2024 at 1500. Review of psychiatric progress note dated 01/01/2025 at 0842 revealed “Pt expecting to discharge today and is safe to do so. Pt with ongoing mood instability and anxiety but is not an acute danger towards self. ...” Patient #20 was discharged home with mother on 01/01/2025. Review of incident reports for Patient #20 revealed documentation of aggression/self-injurious behaviors on 12/06 (times 2) and 12/22/2024. (Total of 3 incidents between 12/06/2024 and 12/22/2024) Review on 01/10/2025 of the medical record for Patient #4 revealed a 16-year-old female presented via law enforcement on involuntary commitment on 12/17/2024 at 1211 with a diagnosis of major depressive disorder, suicidal ideations and hallucinations. Review of the History and Physical documented on 12/18/2024 at 0800 revealed Patient #4 presented with reported command hallucinations “telling her to kill herself by overdose.” Patient #4 had a physical restraint documented on 12/22/2024 at 1900 for attempting to enter the medication room at 1846. Patient #4 had a physical restraint documented on 12/22/2024 at 1900 for jumping over the nurse’s station to obtain contraband at 1850. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #4 was in the group room and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2045. Observation sheet revealed other location and disruptive behavior documented at 2100. At 2106 documentation revealed that Patient #4 had been transported to the Emergency Room. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #4 to an outside facility for evaluation of suspected overdose. Review of psychiatric progress note dated 12/24/2024 at 0944 revealed Patient #4 “with severe anxiety, agitation, and aggressive behaviors. Pt shows poor insight and labile mood.” Psychiatric progress note dated 12/26/2024 at 0920 indicated that Patient #4 was experiencing auditory verbal hallucinations with severe anxiety and recent aggressive behaviors. The patient showed little improvement in mood or behaviors. Review of a psychiatric progress note dated 12/27/2024 at 0929 revealed “Pt denies suicidal or homicidal ideations. Pt denies any current safety concerns regarding personal health care post discharge. Pt has identified positive coping skills that will help pt control mood and construct positive thoughts and proactive behavior. ...” Patient #4 was discharged home with family on 12/27/2024. Review of an incident report for Patient #4 revealed documentation of aggression on 12/22/2024. Review on 01/09/2025 of the medical record for Patient #19 revealed a 14-year-old female presented on 12/17/2024 at 1813 with a diagnosis of Major Depressive Mood disorder and suicidal ideations. Documentation on 12/17/2024 at 1900 revealed that Patient #19 was a high risk for suicide and self-harm with impulsivity and aggressive tendencies. Review of the History and Physical documented on 12/18/2024 at 0800 revealed Patient #19 presented “on a voluntary hold for suicidal ideations and suicide threats made during an altercation with her mother. Mother reports that child has displayed worsening mood lability and has been making more statements that she ‘won’t be here later.’ Review of a social services progress note dated 12/19/2024 at 1045 revealed that Patient #19 was agitated and verbally aggressive. A social services progress note documented on 12/202/2024 at 1440 revealed that Patient #19 was verbally aggressive toward staff. Review of a nursing note documented on 12/20/2024 at 1740 revealed Patient #19 was involved in a verbal/physical altercation with a peer. Patient #19 was administered as needed medication and the medication was effective. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #19 was in the group room and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2100. At 2104 documentation revealed that Patient #19 had been transported to the Emergency Room. Review of psychiatric progress note dated 12/23/2024 at 1007 revealed Patient #19 had not returned from the emergency room. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #19 to an outside facility for evaluation of suspected overdose. Patient #4 was discharged home with family on 12/23/2024 after returning from the emergency room. Review of incident reports for Patient #19 revealed documentation of aggression/contraband on 12/20 and 12/22/2024. (Total of 2 incidents between 12/20/2024 and 12/22/2024) Entrance conference on 01/08/2025 at 0930 with administrative staff revealed the adolescent girls (age 12-17) unit had been changed from C1-North to the C1West-A unit and the children (littles-age 5-11) unit had been changed from C1West-A to the C1-North unit. Two (2) of the seven (7) adolescent females involved in the incident on 12/22/2024 remained in the facility and were located on the C1W-A unit. Interview on 01/21/2025 at 1450 with Staff #76 revealed Staff #76 and Staff #77 worked at Main Campus and responded to the Code One (psychiatric emergency) at the Children’s hospital together. Interview revealed there were two (2) police and a third one pulling into the parking lot when they arrived. Interview revealed that Staff #16 was at the entrance door talking with the police officers. Staff #76 indicated that they were told not to go into the unit related to a potential hostage situation. Staff #10 and a MHT were standing in the hallway outside the unit when Staff #76 and #77 arrived at the unit around 1845. Staff #77 entered the adolescent female unit and Staff #76 entered through the children’s unit. Staff #77 removed patients from the nurse’s station. Staff #76 closed the center door between the units. The patients in the TV (television) room on the children’s (littles) unit were “hysterical and crying.” Staff #14 asked Staff #76 what to do with the children (littles) and was instructed to escort the patients through the courtyard to an empty unit (West-B). Staff #76 entered the adolescent female unit through the center adjoining unit door and indicated that medical records were being thrown in and from the nurse’s station. Staff #77 was attempting to remove a syringe/needle from Patient #5’s hand and was requesting help. No staff on the unit came forward. Staff #76 assisted Staff #77 in removal of the syringe/needle from Patient #5’s hand. Staff #76 revealed “No clue where staff were that responded or were currently on the unit.” Staff #76 indicated that the patients that were not involved in the incident had “barricaded” the dayroom door. Some of the patients were in the alcove/comfort room area near the bathroom. Patient #5 ran out of the nurse’s station and had another syringe/needle in her hand. Patient #5 stood outside the comfort room near the wall and Staff #77 reacted and grabbed Patient #5’s arm to remove the syringe/needle from Patient #5’s hand. Police arrived as Patient #21 jumped Staff #77 from behind and grabbed Staff #77’s head causing the syringe/needle to fall to the floor. The interview revealed that the staff panicked. Interview revealed there were issues with nurse’s not having medication room key fobs. Staff #76 was on the unit on 12/21/2024 and stated that the house supervisor told the nurses to prop the medication room door open. Interview revealed that on 12/21/2024 on the C1-South-Adolescent male unit, the nurse had a key fob, but the key fob would not open the medication room door. Staff #76 stated that the door was propped open and was closed when not giving medications. Staff #76 revealed that the staff did not intervene early enough and should not have been behind the desk interacting with the patients. The interview revealed there was an adequate number of staff if the staff had been proactive. Staff #76 did reveal that the seclusion room was off the unit down the hallway and that there were no staff available to put a patient in seclusion. Interview revealed that Patient #5 had been causing problems for three (3) days. The interview revealed that on 12/21/2024, the nurse and MHT should have moved the patient being attacked to another unit. There was an incident on 12/20/2024 involving the same patients but they did not give the patient medications so that the patient could be discharged. Interview revealed that when the police removed the patients involved in the incident on 12/22/2024, the girls were laughing and singing Christmas carols. Interview revealed that Staff #76 was injured during the incident and required medical treatment. Interview revealed that the drawers/cabinets in the nurse’s station should be locked for safety. Staff #76 returned to work with restrictions, on 01/17/2025. Interview on 01/23/2025 at 1310 with Staff #77 revealed Staff #77 and #76 responded to the children’s hospital together. The interview revealed that when a Code One was called at the children’s hospital, the house supervisor at children’s hospital would notify the house supervisor at the Main campus. Staff #77 indicated that the main campus house supervisor would normally notify the male MHT’s working at Main campus to respond to the Code One at the children’s hospital. Staff #77 revealed that one police arrived about the same time and there were approximately six (6) other police officers at the children’s hospital entrance. Interview revealed that the plan was to try and calm the situation prior to the police going to the unit. Staff #77 entered the adolescent female unit near the dayroom. Staff #77 revealed that the patients were throwing objects, two (2) patients were coming out of the nurse’s station with pill bottles, taunting the staff. The interview revealed there was one (1) patient on the nursing station counter with two (2) syringes in hand. A second patient was walking around with a metal device in her hand. Staff #77 attempted verbal de-escalation with no avail. The interview revealed that Staff #77 analyzed the situation and how to handle who would be removed first and any threatening weapons. Staff #77 then grabbed the two (2) patients with the pill bottles and escorted them out of the nurse’s station, then spoke to and side-tracked the patient with the metal stick, removed the metal stick from the patient’s hand and then escorted the patient out of the nurse’s station. The interview revealed that Staff #77 talked with Patient #5 attempting to get the patient to give up the two (2) syringes/needles. Patient #5 was distracted by another patient, Staff #77 and #76 put the patient in a hold and removed one (1) of the syringes/needles from her hand. One of the patients outside the nursing station threw a telephone and struck Staff #76 in the face/nose. Patient #5 was escorted out of the nurses station. Patient #5 had placed the second syringe down into her shirt/bra. Interview revealed that Patient #5 was standing outside the comfort room, removed the syringe/needle from her shirt/bra and was poking the syringe/needle into her arm. Staff #77 revealed that the patient got sidetracked and looked away and Staff #77 knocked the syringe/needle out her hand. The syringe/needle fell to floor, was picked up and given to Staff #76. Staff #77 indicated that Patient #5 began kicking and fighting. Interview revealed that at the same time Patient #21 jumped Staff #77 from behind and pulled hair. The police arrived and removed Patient #21 from the area. Interview revealed that when Staff #77 arrived on the unit, the staff were huddled in the corner of the nurse’s station. Staff #77 revealed “Did expect staff to follow behind me. Talked with staff without following. I took charge of the situation.” Staff #77 had responded to two other incidents prior to the incident on 12/22/2024 and responded to multiple incidents involving Patient #5 and #21 after the 12/22/2024 incident. Interview on 01/23/2025 at 1607 with Staff #65 revealed that Staff #65 was notified by Staff #6 about the incident on 12/22/2024. Staff #65 revealed that upon arrival to the facility, the adolescent female unit was in “totally disarray.” Police and EMS had arrived at the facility. Staff #65 indicated that “pills” were found on the unit floor during clean up and given to a nurse. The interview revealed that after reviewing the video, Staff #65 identified that no one on the unit identified roles and responsibilities and no early interventions were attempted. Interview revealed that the “ringleader” should have been placed in a “standing high restrictive hold” and escorted off the unit. The interview revealed that other staff should have de-escalated and tried to control the other patients. Interview revealed that the patients should have never been left unattended and that the medication room door should have been closed “the minute the nurse’s station was compromised.” Interview revealed that most of the staff working the evening of 12/22/2024 were new and possibly did not feel confident to make decisions. Interview revealed that the Code One leader should take control and direct staff. Staff #65 revealed that Staff #74 engaged but realized no other staff engaged to help him and pulled out. Interview revealed that there was adequate staff to decrease the threat level, but staff did not use all aspects of their CPI (de-escalation) training to de-escalate the situation. Interview on 01/10/2025 at 1120 with Staff #1 revealed that the pharmacy was not notified of the medication room breach until Monday 12/23/2024. Staff #1 assessed the C1-North/C1-West-A medication room on 12/23/2024 and retrieved a plastic tray that had home medication bottles that had been picked up from the unit/unit floor after the incident. The pharmacist identified a bottle of Concerta (medication used to treat attention deficit disorder) that should have had 12 pills, only had 8 (4 pills missing) and Clozapine (antipsychotic medication used to treat schizophrenia that should have had 21 pills (all 21 were missing). Interview revealed the pharmacist did not recall receiving the medications that were found on the unit. Staff #1 indicated that the pharmacist working on 12/22/2024 made rounds on the unit and saw the medication room door propped open, shut the door and told the staff that the door could not be propped open. Interview revealed the home medications, syringes and needles should have been locked in the cabinets in the medication room and not accessible to patients. Staff #1 was made aware approximately a month ago that not all the nurse’s had medication room key fobs and that the company was not making them any longer. Interview revealed that after the incident on 12/22/2024, the facility placed key lock access on the medication room doors and key fobs were no longer required. Interview on 02/04/2025 at 1115 with Staff #78 revealed that during pharmacy rounding on 12/22/2024, the medication room door on C1-North Adolescent female unit/C1-West-A was propped open with a trashcan. Staff #78 removed the trashcan and closed the medication room door. Interview revealed there were no unit staff present to tell to keep the door closed at all times. Interview revealed that the medication room door should be locked and closed at all times. Interview of 01/21/2025 at 1010 with Staff #75 revealed that the children/littles were moved off the adjoining unit after the police arrived. Staff #75 indicated that the canned sodas were kept in a locked cabinet in the medication room for patient use. Staff #75 revealed that the cabinet in the medication room was not locked during the incident. Interview revealed that all staff except housekeeping received Crisis Prevention Intervention (CPI) training upon hire. Interview revealed that the staff were “inadequately prepared to handle the incident.” The interview revealed that the incident may have been “avoided or not gotten to where it did” if staff had intervened when Patient #5 started escalating. Interview revealed that the staff had “ample” time to close the medication room door prior to the patients breaching the medication room. Incident investigation revealed that the staff “did not initiate their appropriate CPI response training, relied on the presence of ‘large body’ to show up, and were afraid of getting fired for using wrong CPI techniques.” Interview indicated that the administrative staff guaranteed extra staff for the remainder of the week as the plan was to place the patients involved in a gown and keep them on the unit until discharge. Interview on 01/10/2025 at 1230 with Staff #6 revealed that Staff #6 was aware that approximately five (5) staff nurses did not have medication room key fobs. Staff #6 sent an email to hospital leadership about key fob concerns. Staff #6 received response that the concerns were being worked on and staff would need to share the key fobs that were available. Staff #6 received a call on 12/22/2024 from the house supervisor that there was a riot on the unit and requested permission to call the police. Staff #6 notified the Chief Nursing Officer/Chief Operating Officer. The police were at the facility when Staff #6 arrived. After the incident, staff #6 assisted with the medication room and contraband training. Interview revealed that the staff working on 12/22/2024 “did not perform what they had been trained to do and should have moved Patient #21 to a different area where the patient could not be seen or heard by the other patients involved in the incident. Interview on 01/09/2025 at 1050 with Staff #31 revealed that on the evening of 12/22/2024 the census on the adolescent female unit (C1North) was eighteen (18) with two of the 18 adolescent girls programming on the C1W-A unit bringing the census down to sixteen (16). Patient behaviors on the unit prior to the incident on 12/22/2024 were aggressive, oppositional, difficult to re-direct and personality conflicts with other patients. Interview revealed that when patients were on aggression precautions, the staff were expected to vigilantly monitor/watch the patients on the unit. Staff #31 did not recall any patients having any specific staff targets. Interview revealed that Patient #5 programmed on the C1-North unit and liked to come out of the dayroom and roam on the unit. Staff #31 was on vacation when the incident occurred and was updated and briefed about the incident upon returning. Staff #31, while on vacation, was briefed about the incident by Staff #6 and Staff #22. Staff #31 met Risk Management briefly upon return and watched the video. The interview revealed that ginger ale was used in the place of water for some of the patients. Staff #31 was not sure who used and left the soda can sitting on the nurse’s station. Interview revealed the soda can should have been discarded in the trash can in the secured medication room. Interview revealed the staff should have engaged and attempted to get the can away from the patient for safety. Interview revealed the staff attempted verbal de-escalation. The incident was “overwhelming, quite traumatic.” Interview revealed the staff had the skills and knowledge but “staff did not take the next step of CPI (Crisis Prevention Intervention).” Staff #31 did not interview the staff and/or patients involved in the incident. Code One is a psychiatric response for patient behaviors and “out of control” situations. The nurse should document the Code One in the medical record. Interview revealed that Staff #31 assisted with the immediate action plan and collected attestation education forms from the staff. Staff #31 provided verbal education on 12/27/2024 regarding medication room, contraband, pharmacy and nursing house supervisor rounding on the medication room. Interview revealed that on the evening of 12/22/2024 the medication room door was propped open due to the nurse did not have a key fob that would open the door. Staff #31 was unsure as to why the other two nurses did not assist with the key fob issue. Interview indicated that several nurses had not been given key fobs for the medication room due to there were none available in the facility. Staff #31 indicated that the company where the key fobs were purchased no longer made them. Interview revealed that Staff #31 believed the C1North unit was adequately staffed on 12/22/2024. Staff #31 indicated that when there was a staff call-out, the facility attempted via telephone calls to find staff to cover. The interview revealed that the house supervisor was pulled to staff a unit if no other coverage could be obtained. The staff were trained on Crisis Prevention Intervention (CPI) and de-escalation techniques upon hire. Staff attended hospital orientation for two (2) weeks. Week one consisted of a Human Resources day, CPI and CPR. Week two consisted of simulations, break out of staff to department specific training and the last two days (Thursday and Friday) the new hire was paired with another nurse to shadow/conduct tasks. Interview on 01/09/2025 at 1535 with Staff #12 revealed there were approximately fourteen (14) patients in the large dayroom when the event started. Staff #12 indicated that Patient #5 grabbed a soda can from the nurse’s station and ripped it apart. Staff #12 stated that Staff #13 attempted to get the can away from the patient. Staff #12 indicated that the can was hid in a bag. The nurse called for more help and “we were waiting for others to get here.” The staff tried to separate Patient #21 from the other girls. Patient #21 kicked Staff #11 in the face. Patient #21 started throwing objects from the adjoining unit (children - littles) where she had been moved. Interview revealed there were no staff on the children’s unit with Patient #21. Staff #12 stated “should have had two people to stay with Patient #21.” Interview revealed the staff should have moved Patient #5 to another location since she was the most aggressive. Staff #12 revealed there were no consequences for patients acting out. The interview revealed that there should have been more staff. The interview revealed that the medication room door was left opened because the nurses did not have key fobs for the door. Staff #12 indicated that the door to the nurse’s station was broken and was repaired the day after the incident. The interview revealed that Plexiglas was placed around the computer monitors “a couple of days ago.” Interview revealed that Patient #5 programmed and slept on the C1-North unit. Interview on 01/09/2025 at 1610 with Staff #10 revealed that on a “usual day” the patients were “pretty calm, redirectable.” On 12/22/2024, around 1430, the unit received candy/cookie bags from Santa. Shortly after the visit, the patients began to talk loudly, became volatile stating that “they should start a fight or riot.” Staff #10 reported this to the House Supervisor and indicated that more staff may be needed. The interview revealed that knowing the history of the patients, Staff #10 believed that it would take more than two (2) nurses and two (2) mental health technicians. Interview revealed that neither nurse working on the C1-North unit had medication room fobs. Staff #10 did not see Patient #5 remove the can from the nurse’s station but they did see the patient pouring the liquid from the can onto the unit floor. Staff #10 indicated that Patient #5 bragged about having the can and told staff that they “would have to fight me to get can back.” Staff #10 went out onto the floor with other staff to try and get the can. During this same time, the other patients were getting “riled up.” The staff were unable to get the can from Patient #5 and Staff #10 did not know what happened to the can. Staff #10 revealed that patients were heard saying “Can’t fight Staff #11, she’s too pretty and Staff #10 was too old.” Patient #21 was placed in a hold and moved to the “other side” (adjoining unit). Staff #10 indicated that the patients on the adjoining unit were monitored by mental health technicians and were later moved to another area. The interview revealed that the staff were behind a wall in the nursing station trying to get help. A Code One was called. The Code One would only be heard within the children’s hospital and the house supervisor would have to call via telephone over to the main campus for additional help. The house supervisor/charge nurse on C1-West-A called the police and then went to front lobby to await police arrival. Police officers were assisted to the unit when they arrived by the house supervisor. Staff #10 went to front lobby to await the arrival of other officers and was not allowed to return to the unit per the police officers. Staff #10 did not recall a nurse trying to hit the patients, “believe I was in shock.” Staff #10 recalled a mental health technician “pushed them down.” Staff #10 did not “feel” that patients were safe with the number of staff based on the patient’s acuity. The patients were aggressive and the staff feared for their own safety. Interview revealed that one nurse was struck in the face with a telephone and another nurse was hit in the side of the head with an I-pad. The interview revealed that multiple patients were discharged to decrease the census to equal the current staffing. Interview on 01/10/2025 at 1205 with Staff #13 revealed the incident began after dinner. Staff #13 stated “I don’t recall if I was on unit. I know there was a situation about a can. When I realized it, the can was ripped or something. She (patient #5) was putting it in her bra. We have to get it without being cut. I do remember saying to the nurse we got to get that. Everything happened so fast seemed like one thing after another and it got out of control fast.” Staff #13 did not know what happened to the can. “It seemed like things started happening. I did not expect that to happen that way. I was also thinking of the little kids and them crying. I do feel safety was an issue ‘at that moment. Dangerous with the can.’ Everyone’s safety, everyone was at risk at that point. I was there and I don’t remember every specific thing.” The staff were asked if they were okay and “I said I was fine.” Staff #13 stated she was “trying to take it in like this really happened. When I left I thought thank God I’m alive. Someone could have gotten seriously hurt.” The interview revealed that after the incident Staff #13 thought more communication would have helped. “If the can were communicated a little better, we could have done something else. It caught us off guard even though we work in these places.” Staff #13 indicated that looking back closer observations of the patients should have been done. “I couldn’t believe it when I hear she (patient #3) was in the ceiling, I couldn’t even believe it.” Staff #13 did not recall how many patients were on the unit and indicated that the door to the nurse’s station was not broken. The interview revealed that Staff #13 did recall the medication room door was propped open. Interview revealed that Patient #5 had been involved in incidents every day since admission (12/17/2024). Staff #13 reported to work the following day. Staff #13 revealed that there had been some changes made since the incident that included better communication and “people are moving,” Staff #13 had not noticed an increase in staff on the unit. Staff #13 indicated that if staff had been told about the patient having the can , “Maybe we could have de-escalated.” Staff #13 revealed that this interview was the first time she had talked one-on-one about the incident. Staff #13 revealed the incident was discussed in a huddle and debriefing. Interview on 01/20/2025 at 1250 with Staff #74 revealed a Code One was called and Staff #74 responded. Staff #74 was instructed to assist with separating a group of girls that were acting out. Staff #74 recalled someone mentioning a can but never did see the can. Several staff members placed Patient #21 in a hold and the other 3-4 patients stood to the side in front of the nurse’s station as if they wanted to attack the staff. The other patients started to throw objects at the staff that were trying to place Patient #21 in a hold. Interview revealed that it took six (6) staff members to place Patient #21 in a hold to move her to the adjoining unit. Interview revealed that Staff #74 attempted to block the objects that were thrown at the staff. The patients were throwing whatever they could get their hands on. Staff #74 stated “I tried to stop them from getting stuff from the nurse’s station.” The situation got progressively worse. I started getting hit with things. Interview on 01/14/2025 at 1255 with Staff #3 revealed that Staff #3 was notified about the incident by Staff #6 around 2000 on 12/22/2024. The interview revealed that Staff #3 was on the Adolescent girls unit the morning of 12/22/2024 and stated, “saw kids ramping up.” Interview revealed that per video review of the 12/22/2024 incident, the unit appeared to have had adequate staff to handle the situation, “unfortunately staff did not engage after the riot situation.” Staff #3 stated that “Staff did not do anything to stop the patients.” Staff #3 indicated that the staff needed additional training other than just Crisis Prevention Intervention. Staff #3 revealed that the facility was “hiring inexperienced staff that have never worked with mental health patients.” Interview on 01/15/2025 at 1135 with Staff #16 revealed that Staff #16 typically worked as a nurse on the unit during the week and as the house supervisor on the weekend. Interview revealed that Staff #16, more often than not, worked as a floor nurse. Interview revealed that there was a nurse call out on 12/22/2024 and no coverage could be found. Staff #16 worked as the unit nurse and the house supervisor on 12/22/2024. Staff #16 revealed that based on the acuity of the adolescent female patient, Staff #16 felt that that unit needed two nurses. Two nurses were assigned to the adolescent female unit and Staff #16 worked as the nurse on the children’s unit. Staff #16 indicated that two nurses were needed in the event that Staff #16 had to attend to house supervisor duties. The interview revealed that there were patient’s acting out on the children’s unit and one of the patients spit in Staff #50’s face. Staff #16 revealed that Staff #50 left the unit to calm down. Staff #16 told Staff #50 to go the C1-West-B unit and relieve Staff #14 and send Staff #14 to cover on C1-West-A. Staff #50 told Staff #16 “No.” Interview revealed that Staff #14 did eventually come to the C1-West-A unit but that Staff #16 did not know if Staff #50 was on the C1-West-B unit (two patients on the West-B unit). Interview revealed that Staff #10 told Staff #16 that Patient #5 had gotten a can and that they would need help. Staff #16 indicated that there was nowhere to pull staff from and that staff would only be called for an emergency. Staff #16 heard the Code One called as Staff #16 was dealing with the kids acting out on the adjoining unit. The interview revealed that the Patient #21 had been moved from the adolescent female unit to the children’s unit and was attempting to climb over the nurse’s station. Interview revealed the staff were “huddled up behind the wall in the nurse’s station.” Staff #16 attempted to talk Patient #5 into giving up the telephone she was swinging over the nurse’s station. Interview revealed “should not have been allowed to happen, staff trained.” Interview revealed that the two nurses working on the adolescent female unit did not have key fob access to the medication room and the room door was propped open. Interview on 01/17/2025 at 0935 with Staff #33 revealed that Staff #22 notified Staff #33 concerning the incident on 12/22/2024. Staff #33 responded to the facility. Staff #33 indicated there were approximately 15 police cars in the parking lot and several ambulances. The interview revealed the patients were already in transition with emergency medical services (EMS) when Staff #33 arrived on the unit. The interview revealed that Staff #33 spoke briefly with a patient that was heading out of the unit by EMS. Interview revealed that Staff #33 evaluated one (1) of the seven (7) patients that were being transferred to Hospital B prior to leaving the facility. The interview revealed that EMS assessed and evaluated the patients prior to transport. Interview revealed that none of the patient showed signs of intoxication. The interview revealed that Staff #33 communicated with the Chief Medical Officer of Psychiatry at Hospital B and provided medical information for the seven (7) adolescents. Staff #33 revealed that the parents/legal guardians of the seven (7) patients were contacted by telephone and that Staff #33 was able to reach approximately 80% of the parents/guardians. Staff #33 left voice messages for the remaining parents/guardians. The interview revealed that Staff #33 documented the parents/guardians notification in the medical record several days after the incident happened. Interview revealed that Staff #33 completed the documentation in the physician progress notes and gave to the medical records director to be placed in the medical record chart. Telephone interview on 01/17/2025 at 1525 with Staff #14 revealed a Code One was called for the C1-North unit and Staff #14 responded from the C1-West-B unit. Interview revealed there were two adolescent females from the C1-North unit programming on the C1-West-B unit when incident occurred. The interview revealed “The biggest problem was lack of leadership, no one shouting orders.” Staff #14 revealed that the patients had pulled metal strips from the ceiling and were pulling and removing contraband from the nurse’s station. Interview revealed that “(Name) made bad calls and placated the kids in front of her without considering other patients.” In summary, the hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications resulting in an unsafe environment for the delivery of care to adolescent female behavioral health patients.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 34065 Based on observations, review of policy, and interviews of staff, the hospital staff failed to provide and/or assist with hygiene needs for 1 of 1 patients observed with lack of proper hygiene; and failed to evaluate a patient for falls risk in 1 of 1 patients observed with unsteady gait. (Patient #40). The findings include: Observation on 01/13/2025 at 1200 during a tour of a patient care floor revealed Patient #40, drooling and with shaking hands, sitting at a table in the dayroom attempting unsuccessfully to open an orange juice container. Observation revealed Patient #40’s medium length brown hair was oily and unbrushed and the front of her shirt had dried stains extending down to her pants. Observation revealed Patient #40 had dried food residue on her mouth and cheeks. Observation revealed Patient #40 was unsteady while walking around the unit. Review of a policy on 01/13/2025 titled “Nursing Standards of Care” with revision date of 01/20, revealed “POLICY: It is the policy that all patients admitted to (Facility A) will have their nursing care delivered in accordance with established standards of care and practice. It is also policy that these standards be written, objective and used in the measurement of quality care. Assessment: Standard of Care: The patient is assessed by the nurse in a timely, comprehensive, accurate and systematic manner. Standard of Nursing Practice: The nurse continuously and systematically collects, records and analyzes data that are comprehensive and accurate....a. The assessment will include a review of the patient biopsychosocial status, environment self-care abilities deficits....Activities of Daily Living: Standard of Care: The patient can expect direction, assistance and supervision of his/her activities of daily living in supporting and promoting patient independent function in this area.” Review of a policy on 01/13/2025 titled “Fall Prevention” with revision date of 05/22, revealed “(Facility A) assesses all patients’ falls risk and implements individuals measures designed to prevent falls and reduce potential injuries. General environmental risks should also be reduced to prevent falls...A fall is defined as an unintentional event that results in a person coming to rest on the ground or other lower level. An unsteady patient who is fully assisted by staff members is not considered a fall...PROCEDURE: Assess all patients Upon Admission. A falls risk assessment is completed to evaluate and identify those patients who may be at risk of falling. The falls risk assessment process provides the nurse with an opportunity to evaluate the patient’s potential for falls and allows the nurse to instruct the patient as to his/her responsibilities for preventing falls. All patients will be assessed for fall potential during the Admission process.” Review of a policy on 01/13/2025 titled “Patient’s Bill of Rights” with revision date of 06/2016, revealed “As a Patient, you have the right: 1. To considerate and respectful care in a safe environment with respect to personal dignity, values, beliefs, privacy, humane care, freedom from mental and physical abuse, neglect and exploitation, and to live as normally as possible while receiving treatment.” Review of an open medical record on 01/15/2025 revealed Patient #40 was a 41 year old female who was transferred from an outside facility with IVC (involuntary commitment) orders for admission on 01/02/2025. Patient #40 had not slept in 4 days and was noted to be paranoid (suspicious), anxious (worried), and disorganized at the time of her presentation to the facility. Review of the daily nurse progress notes revealed Patient #40 was “independent” of ADL’s (Activities of Daily Living: Bathing). Review of the medical record from 01/02/2025 through 01/13/2025 revealed no documentation of a shower/bath or hygiene. Review revealed no documentation of a falls risk. Interview on 01/13/2025 at 1205 with Staff #49 revealed Patient #40’s hair looked “unwashed” and needed attention. Interview revealed patients were evaluated for falls risk upon admission. Interview revealed no falls evaluation on Patient #40 was documented in the medical record. Interview on 01/13/2025 at 1500 with Staff #9 revealed Patient #40 should have been evaluated for a falls risk upon admission and a shower chair should have been ordered for safety in the shower.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 50111 Based on review of hospital policies, medical records and staff interviews, the hospital failed to ensure an accurate medical record by failing to document a change in physical status and procedures performed during an emergency medical situation for 1 of 2 patient deaths reviewed (Pt #1). The findings include: Review on 01/15/2025 of hospital policy “Code Blue (a life-threatening medical emergency) Procedure,” last reviewed 01/2020, revealed, “... The nurse will complete the Code Blue Record including the names of those who participated in the code ... The ‘Change in Physical Status’ form will be completed by the nurse documenting events occurring up to the initiation of the Code Blue Procedure and placed in the patient’s chart ...” Review on 01/15/2025 of hospital policy “Change in Physical Status,” last reviewed/revised 03/01/2021, revealed, “... 2. The Licensed Practical Nurse (LPN) shall: ... a. Observe individuals for any changes in physical status ... c. Document observations and communications to the RN (Registered Nurse) or physician in a progress note ... 3. The RN (Registered Nurse) shall: ... Document an initial nursing progress note briefly describing the individual’s change in physical status ...” Closed medical record review on 01/08/2025 for Patient #1 (Pt) revealed a 39-year-old male who arrived to the hospital on 06/06/2024 at 0248. Review of the Intake Assessment at 0321 revealed the patient presented for a suicide attempt by overdose on Keppra (a seizure medication) and other unnamed psychotropic medications (medications used to treat mental health conditions). Review of the Intake Assessment revealed the On-Call Provider was notified at 0340. Record review revealed Pt #1 was admitted at 0410 with a diagnosis of major depressive disorder and alcohol use. Review of the Vital Signs at 0530 revealed a blood pressure of 117/77 (below 120/80 is considered normal blood pressure), a respiratory rate of 19 (normal range is 12 to 20), a heart rate of 69 (normal range is 60 to 100), and an oxygen saturation (level of oxygen in the blood) of 98 percent (normal range is 95 to 100 percent). Review of the Nurse Note on 06/06/2024 at 1630 revealed, “... Responded to call by the unit LPN of patient being unresponsive in the room at around 1020 hrs (hours). Code blue called. Found patient partially face down tilted to the left side, called on patient, unresponsive to touch & (and) shake. Checked for pulse but unpalpable. Turned patient supine (onto back) and initiated chest compression (sic). As help arrives including code cart connected the pads and the AED machine (Automated External Defibrillator- used to treat a person whose heart has stopped) as compression was ongoing. Called for ambubag (a mask and bag used to deliver oxygen or air to a person) & (and) yankauer (suction tip) for suction as foam was coming out of his mouth and nostril. (Staff #18) managing airway, (Staff #19) assisting with chest compression. (Staff #18) obtained pulse during CPR (Cardiopulmonary Resuscitation) unable to obtain blood pressure. Oxygen saturation 69 % (percent) on machine. EMS (Emergency Medical Services) arrived and took over the CPR. The EMS continued with CPR and later pronounced time of death as 1052 hours.” Review of the Medicine Consult Note, no date or time documented, revealed, “I heard the code called at 10:33am ... Pt was unresponsive and cynotic (sic) with extremities purple blue and face blue ... he was unresponsive, not breathing and does not have a pulse. I assisted with three person CPR ... Eyes were dilated with minimal reaction to light ... I continued to open the patient’s airway with minimal success due to patient’s jaw being locked due to rigor (stiffening of the joints and muscles after death). 1x (One time) narcan (a medication that can reverse the effects of narcotics in an emergency situation) 0.4mg (milligrams) provided at appx (approximately) 1042am. EMS arrived appx 1045 and handoff was performed and my care of the patient ended.” Review of the Discharge Summary on 06/17/2024 at 0428 revealed, “... the patient was pronounced dead at approximately 10:50 ... Upon approach, he was found to be lying in bed, face down. As writer entered the room, staff did turn the patient over and noted him to be stiff and purple/blue in his extremities. He was nonverbal. His eyes were not reactive to light. He remained unresponsive throughout CPR ...” Medical record review failed to reveal a Code Blue Form, a Change in Physical Status Form or a Progress Note at the time of the Code Blue. Interview on 01/09/2025 at 1200 with Staff #20 revealed there was no additional Code Blue documentation for Pt #1. Interview revealed all Code Blue documentation should have been placed in the patient’s medical record. Interview on 01/14/2025 at 1021 with Staff #49 revealed hospital staff were expected to document Code Blue information on the Code Blue Form. Interview revealed Code Blue documentation should have been reviewed by the unit manager and placed in the patient’s medical record.”

“CONTENT OF RECORD: FINAL DIAGNOSIS CFR(s): 482.24(c)(4)(viii) [All records must document the following, as appropriate:] Final diagnosis with completion of medical records within 30 days following discharge This Standard is not met as evidenced by: 50318 Based on review of hospital policy, medical records, and staff interviews, the hospital failed to ensure a discharge summary was completed within 30 days following discharge for 4 of 59 sampled closed medical records reviewed (Pt #9, #35, #10, #34). The findings include: Review on 01/24/2025 of hospital policy “Medical Records Completion,” last revised 11/2023, revealed, “... Discharge Summaries must be dictated within thirty days from the date of discharge ...” Review of the Medical Staff Rules and Regulations adopted 01/29/2024 revealed, “... 5.3.2 Member and Provider Responsibility for Medical Record Providers are responsible for ensuring that the following are dated, documented legibly, and in chronological order in each patient’s medical record: ... diagnoses at the time of discharge. Members must complete the discharge summary within 30 days of discharge. ...” 1. Closed medical record review on 01/09/2025 for Pt #9 revealed a 32-year-old patient who was involuntarily committed on 05/11/2024 with a diagnosis of schizophrenia (a disorder that affects a person’s ability to think, feel, and behave) and increased aggression (violent attacking behavior or attitude toward another person) with staff at his group home. Pt #9 was discharged to a shelter on 05/20/2024. Record review failed to reveal a Discharge Summary for Pt #9. Interview on 01/14/2025 at 1612 with Staff #53 revealed the Discharge Summary for Pt #9 had been dictated but had not yet been sent to the facility to be printed. Staff #53 was unable to provide evidence of what had been dictated. Interview on 01/24/2025 at 1130 with Staff #9 revealed Discharge Summaries should be completed within 30 days of discharge for all inpatients. 2. Closed medical record review on 01/09/2025 for Pt #10 revealed a 27-year-old patient who was involuntarily committed on 10/25/2024 with a diagnosis of schizophrenia with aggressive behaviors and homicidal ideations (HI - harming others). Discharge Summary: Disposition and After Care revealed, “no disposition or aftercare follow-up appointment was found in the chart.” Pt #10 was discharged on 11/05/2024. Record review revealed the Discharge Summary was dictated on 12/27/2024 (52 days after discharge). Interview on 01/09/2025 at 1014 with Staff #8 revealed the discharge paperwork regarding Pt #10’s disposition and aftercare should be in the chart, but it was not. Staff #8 was able to locate an appointment that had been made for Pt#10 at an outpatient clinic but was unsure of the date or time. Interview on 01/24/2025 at 1130 with Staff #9 revealed Discharge Summaries should be completed within 30 days of discharge for all inpatients. Staff #35, who assisted with Pt #10’s discharge, no longer worked at the facility. 50111 3. Closed medical record review on 01/15/2025 for Patient #35 (Pt) revealed a 44-year-old male admitted to the hospital on 09/25/2024 at 2308 with a diagnosis of schizophrenia (a disorder that affects a person’s ability to think, feel, and behave clearly). Pt #35 was discharged home on 10/10/2024 at 1420. Record review failed to reveal a Discharge Summary for Pt #35. Interview on 01/24/2025 at 1130 with Staff #9 revealed Discharge Summaries should be completed within 30 days of discharge for all inpatients. 4. Closed medical record review on 01/15/2025 for Patient #34 (Pt) revealed a 27-year-old male admitted to the hospital on 09/28/2024 at 1235 with a diagnosis of substance abuse and major depressive disorder. Pt #34 was discharged home on 10/04/2024 at 1117. Record review revealed the Discharge Summary was dictated on 11/17/2024 (44 days after discharge). Interview on 01/24/2025 at 1130 with Staff #9 revealed Discharge Summaries should be completed within 30 days of discharge for all inpatients.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 26622 Based on review of hospital policy, video review and staff interviews, the hospital failed to ensure that medications were kept in a secure area. The findings include: Review of hospital policy, “Medication Administration”, revised 05/2022, revealed “Procedure ... 20. Staff will never leave the Medication Cart or Medication Room unlocked. ...”. Review of hospital policy, “Medication Management”, revised 09/2020, revealed “Procedures for Children’s Hospital ... 5.1 The intake staff will record home medications taken into custody at the time of admissions. ... 5.2 The intake staff will place patient home medications in a tamper-resistant security bag with a copy of the inventory form attached to the outside. The bag will be sealed and taken to the unit where the patient is admitted and given to the floor nurse ... 5.3 The nurse will secure the bag in the cabinets located in the medication rooms. These cabinets are kept locked when not in use. ...” Review of hospital policy, “Medication Rooms Access and Key Control”, revised 01/2020, revealed “Policy ... implement appropriate measures to ensure only authorized individuals have access to the unit medication room. Video review on 01/08/2025 at 1445 of an incident that occurred on 12/22/2024 at 1830 revealed the medication room door was propped open. Review of the video revealed syringes with needles and an unknown medication vial were left unsecured on the medication room countertop. Interview on 01/10/2025 at 1120 with Staff #1 revealed that the pharmacy was not notified of the medication room breach until Monday 12/23/2024. Staff #1 assessed the C1-North/C1-West-A medication room on 12/23/2024 and retrieved a plastic tray that had home medication bottles that had been picked up from the unit/unit floor after the incident. The pharmacist identified a bottle of Concerta (medication used to treat attention deficit disorder) that should have had 12 pills, only had 8 (4 pills missing) and Clozapine (antipsychotic medication used to treat schizophrenia that should have had 21 pills (21 pills missing). Staff #1 indicated that the pharmacist working on 12/22/2024 made rounds on the unit and saw the medication room door propped open, shut the door and told the staff that the door could not be propped open. Interview revealed the medications, syringes and needles should have been locked in the cabinets in the medication room and not accessible to patients. Interview on 02/04/2025 at 1115 with Staff #78 revealed that during pharmacy rounding on 12/22/2024, the medication room door on C1-North Adolescent female unit/C1-West-A was propped open with a trashcan. Staff #78 removed the trashcan and closed the medication room door. Interview revealed there were no unit staff present to tell to keep the door closed at all times. Interview revealed that the medication room door should be locked and closed at all times.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 36956 Based on observations, review of policy and procedures, medical record review patient and staff interviews facility failed to maintain a clean and sanitary environment by not ensuring patient group dayrooms were free of pest (1 East); failing to ensure a Patient’s room was free of ants (patient #7 -1 West); and failing to provide an environment that was free of dirt, dust, stains, paper trash, and holes in the dry wall for 3 of 9 units toured (1 East, 1 West and 2NB - main campus). The findings include: 1. Observation on 01/13/2025 at 1340 during tour of the 1 East Unit revealed upon arrival to the unit there were patients in the hallway and patients in the group dayroom. This surveyor entered the dayroom. Patient #47 stepped inside the dayroom from the hallway and stated, “there are roaches crawling all behind there” and pointed to the coffee machine on the counter. An unnamed female patient spoke up and stated, “yeah they are always crawling along down there” and pointed to the floor base of the cabinet and the floor. After this surveyor moved the coffee machine forward, observation revealed large and small roaches crawling on the back of the countertop. Observation to the counter base at floor level revealed dirt and a sticky floor. Observation revealed 2 large bowls of fruit (oranges) at the end of the countertop. Interview on 01/13/2025 at 1345 with Staff #22 revealed when this surveyor asked if staff #22 saw the roaches behind the coffee machine, staff #22 stated “they’re there.” Interview on 01/13/2025 at 1347 with patient #47 revealed the patient was admitted to 1 East on 01/10/2025. Interview revealed the patient observed roaches when the patient first arrived in the unit. The patient stated “I spoke to the staff RN (Registered Nurse) about it. I killed it and showed it to her. I was told to throw it away.” Interview revealed patient #47 identified the RN as staff #25. Interview revealed roaches were everywhere in the fruit bowls on the counter, on the sugar packs and ice machine. Interview on 01/13/2025 at 1510 with staff #25 revealed, when asked by surveyor regarding a patient showing staff #25 a dead roach, staff #25 instructed the patient to throw the roach away. Staff #25 replied “she told me but I don’t remember seeing one. There were several staff around and someone said ’”throw it away.”’ Interview revealed staff #25 stated “I did not say that.” Review of a hospital policy titled “DAILY CLEANING PROCEDURES ...DISTRIBUTION: HOUSEKEEPING DEPARTMENT with the latest revised date of 06/2020 revealed, “ POLICY In order to maintain the hospital facilities in a clean, sanitary, orderly and attractive condition and to provide a suitable environment for the care of patients ...the following procedures have been identified .....CLEANING PROCEDURES ...4. Cabinets and Cupboards: Clean on the outside with Neutral Disinfectant Cleaner ...Clean tops underside and knobs, ....” Review of hospital policy titled “FUNCTION OF HOUSEKEEPING with a reviewed date of 01/2023 revealed, “...POLICY ...to maintain a clean and comfortable environment for patients, employees, medical staff and general public ....PROCEDURE ...The responsibilities of Environmental Services Manager and Lead Housekeeper are: 1. To establish a current, written organizational plan outlining the care and cleaning of the facility ....5. To regularly review the performance of housekeeping personnel through evaluations of quality and quantity ....6. To maintain adequate communication with all other departments and personnel in the facility through inspections and meetings.” Review of documentation titled “ENVIRONMENTAL SERVICES SUPERVISORY INSPECTION FORM” for the 1 East Unit was reviewed for the sampled months 06/2024 - 12/2024. Review revealed inspections were to be conducted daily on the 1 East Unit and any issues or concerns were to be reported to the attention of the supervisor. Review revealed staff documented concerns with check marks in the “No” column, written comments in the comment column and comments at the bottom of the form for the following dates: June and July, 2024 “EATING IN DAY ROOM (MEALS) ...MEALS ATE IN DAY ROOM; August 2024 patients were eating meals in the dayroom; September 2024 staff documented at bottom of form “StAff still Allowing pAtients to EAt in Rooms. Ants in Room 105” Review of a second inspection form for September and October, 2024 revealed all the meals were eaten in the dayroom/ unit; October 2024 revealed staff document at the bottom of the form the patient continue to eat in “Rooms” Review revealed for November 2024 staff documented on inspection form staff “has a hard time cleaning the day room. Patients do not leave ... (staff #49) ...is aware) ...Eating in rooms causing Ants” Review of December 2024 inspection form revealed staff documented “How can we stop patients from eating in rooms ....How can we get the dayroom for at least 45 mins to clean ....How can we get staff to help with after meals clean up” Review of a second December inspection form revealed staff documented for the dayroom/patient chairs, tables ...Roaches, Food Eating All meals ...Patient do not leave Day room.” 2. Medical record review on 01/11/2025 revealed Patient #7 a 35 year old male was IVC’d and admitted to the hospital on 08/12/2024 at 1949. Review of the “HISTORY AND PSYCHIATRIC EVALUATION” by staff #66 dated 08/13/2024 at 1200 revealed Patient #7 was non-compliant with medication and was IVC’d because he threatened family with a knife. Further record review revealed Patient #7 was admitted to the 1 West Unit. Review of “Psychiatric Progress Note by staff #72 dated 08/17/2024 at 1400 revealed 5 days after admission Patient #7 complained of itching to his left arm and patient stated, “felt like an insect bite.” Review revealed Patient #7’s “L (Left) arm appeared red.” Review of a Psychiatric Progress note by staff #72 dated 08/20/2024 at 1535 revealed Patient #7 reported something was biting him on his L arm and it makes him upset.” Continued review revealed staff #72 placed an order for a Medical Consult. Review of a “Medicine Consult Note” by staff #18 dated 08/21/204 at 1600 under the HPI (History of Present Illness) section revealed Patient #7 reported “ ...a spreading vesicular (small fluid filled blister) rash over his abdomen that started 3d (days) ago. 2d ago it came on his arm. Yesterday it spread to his leg. sx (symptom) include pruritic (itching) ...has not tried anything” “Physical Exam” revealed “Several viscous in a linear fashion on umbilical region several viscous grouped on the back of R (right) leg open superficial abrasion on L forearm ....Impressions/Recommendations ...Arthropod (insect) bites: -acute, no s/s (signs and symptoms) infectious. Add hydrocortisone (itching relief medication) TID (three time a day) prn (as needed) for sx (symptom) relief” Interview on 01/14/2025 at 1249 with staff #73 revealed Patient #7 was admitted to the unit in room 117 near the nursing station. Interview revealed the patient complained he was bitten by ants in his room. A medical consult was done for staff #18 and the results was a red rash. Interview reveal staff #73 called in a work order for maintenance and notified staff #23. Interview revealed maintenance arrived immediately and sprayed the patient’s room. Interview on 01/15/2025 at 1125 with staff #72 revealed staff #72 observed patient #7’s arm was swollen and had a rash. Interview revealed staff #18 observed patient #7’s arm, stomach and legs regarding the rash. Interview revealed staff #73 called maintenance regarding bugs in patient’s room. 34065 3. Observations on 01/13/2025 at 1145 through 1245 during a tour of a patient care floor (2NB Main campus) revealed dried splatter stains on the wall near the phone in the day room. Observation revealed 3 (three) spots of drywall missing exposing the inside of the wall. The areas of the wall were various sizes with the dust of the damaged walls observed on the floor beneath the damaged wall. Observation of the chairs in the day room revealed trash beside the cushions of the chairs. Observation of the nurses desk revealed a wood like board under the nurses desk on the floor with protrusions of 4 nails on the board. Observation revealed multiple wires exposed on the wooden box attached under the desk. Observation revealed when the board was removed, a layer of dust was found under the board with a penny and a bead. Review on 1/16/2025 of the procedure titled “...Environmental Services: Daily 7 step Cleaning & Sanitizing Procedure” with revision date of 08/13/2024 revealed “The seven-step cleaning process includes emptying the trash; high dusting; sanitizing and spot cleaning; restocking supplies; cleaning the bathrooms; mopping the floors; hand hygiene and inspection. 1. Pull trash--daily. 2. High Dust--Twice weekly. 3. Damp wipe--daily. 4. Clean/sanitize bathroom--daily. 5. Ice Machines--Daily. 6. Floor Care---daily. 7. Inspect the room--daily. Report any needed repairs. Correct any deficiencies....” Interview on 01/16/2025 at 1615 with Staff #23 revealed “painters arrive every 2.5 weeks per the contract for repairs.” Interview added more employees are needed to cover the facility. “There is only one supervisor and not enough of us to get around for inspections. It is a challenge to get around for inspections.” Interview on 01/16/2025 at 1145 with Staff #49 revealed the concerns should have been reported when found. Interview revealed the repairs were needed soon for safety.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 36956 Based on observations and staff interviews facility failed to prevent and control the transmission of infection by failing to remove chairs with torn seat coverings from patient use for 2 of 3 patient group dayrooms (2 West, 1 East) on the main campus and 2 of 3 units toured on the Childrens campus (C1 West adolescent female unit and C1 North children’s unit). The findings include: 1. Observation on 01/08/2025 at 1130 during tour of the 2 West Unit revealed male and female behavioral health patients in the group dayroom. Observations revealed 20 patients gathered in the dayroom for a Recreational Therapy session and later patients exited the dayroom. This surveyor asked the staff to move the chairs away from the wall and windows. Observation revealed the seat coverings were cracked and peeling. Further observation revealed 4 of 26 chairs had large tears to the seat cushions. Observation revealed the floor was black, dirty with grit and was sticky. Interview with staff #23 and staff #24 on 01/09/2025 at 1413 revealed per staff #23 housekeeping staff had a difficult time cleaning the dayrooms because the unit staff does not always take the patients off the unit to the cafeteria. Review revealed the cleaning staff had a difficult time cleaning the dayrooms Review reveal per staff #24 the dayroom not being clean is a infection cross-contamination problem. 51294 2. Observation of C1 West (adolescent female unit) on 01/09/2025 at 1545 revealed 3 chairs with large areas of outer covering exposed to reveal fabric underneath in the activity room. 3. Observation of C1 North (children’s unit) on 01/09/2025 at 1510 revealed 5 chairs with holes with fabric underneath exposed, red dried substance on a wall and floor and sink area with exposed pegs under the sink in the large activity room. Interview on 01/09/2025 at 1545 with leadership staff during the tour confirmed the chair covers were torn and had holes in them making it difficult to clean the chairs.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 50111 Based on review of hospital policies, medical records and staff interviews, hospital staff failed to ensure a Master Treatment Plan was completed and/or updated for 21 of 72 medical records reviewed (Pt #34, #35, #39, #52, #54, #59, #44, #46, #19, #40, #24, #26, #10, , #39, #12, #25, #28, #31, #14, #68 and #16). The findings include: Review on 01/23/2025 of hospital policy “Interdisciplinary Patient-Centered Care Planning,” last reviewed on 04/2024, revealed, “... Developing the Treatment Plan ... 4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan ... The treatment team will complete the MTP (Master Treatment Plan) including: ... b. Completion of Individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem, specific behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention ... Interdisciplinary Treatment Plan Update ... 1. ... The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum of every (7) seven days after the completion of the Master Treatment Plan ... The following would be cause for conducting a review of the plan and developing a revision: ... A new impairment/problem ... 2. ... a. ... Once a goal has been resolved, the date will be identified on the treatment plan ... c. Staff members, upon discharge, shall either document on remaining goals the date if resolved or ‘ongoing’ meaning that the problem has not yet been resolved ...” Review on 01/24/2025 of hospital policy “Documentation Requirements In The Medical Record,” last revised 11/2023, revealed, “... Treatment Plan ... 14. Behavior management plans shall be written as part of the Treatment Plan ...” 1. Closed medical record review on 01/15/2025 for Patient #34 (Pt) revealed a 27-year-old male admitted to the hospital on 09/28/2024 at 1235 with a diagnosis of substance abuse and major depressive disorder. Review of the Nurse Note on 09/29/2024 at 2000 revealed, “Pt. was transferred today ... because of inappropriate sexual contact with a female pt ...” Review of the medical record revealed a blank Interdisciplinary MTP. Record review failed to reveal documentation of a MTP, a Behavior Management Plan or Individual Problem Sheets during Pt #34’s admission (6 days). Pt #34 was discharged home on 10/04/2024 at 1117. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should have been completed within 72 hours of admission and signed by the Therapist, RN (Registered Nurse), and the Provider. Interview on 01/24/2025 at 1340 with Staff #9 revealed there was no MTP, Individual Problem Sheets, or a Behavior Management Plan completed for Pt #34. Interview revealed the MTP should have been initially developed and then updated after an event occurred if the problem was not previously included in the MTP. Interview revealed a Behavior Management Plan should have been completed within 24 hours the event as part of the treatment plan. 2. Closed medical record review on 01/15/2025 for Patient #35 (Pt) revealed a 44-year-old male admitted to the hospital on 09/25/2024 at 2308 with a diagnosis of schizophrenia (a disorder that affects a person’s ability to think, feel, and behave clearly). Review of the MTP on 09/26/2024 revealed, “Problem #1: Psychosis (loss of contact with reality) ... Problem A: HTN (hypertension- high blood pressure) ... Problem B: Diabetes (when the body doesn’t produce insulin properly) ...” Review of the Medical Problem Sheet failed to reveal a target date for the problem of diabetes. Review of the Medical Problem Sheet failed to reveal if Pt #35’s goals were achieved for the problems of diabetes and HTN. Record review failed to reveal documentation of an Individual Problem Sheet for Psychosis during Pt #35’s admission (14 days after the MTP was initiated). Review failed to reveal evidence of a MTP update during Pt #35’s admission (14 days after the MTP was initiated). Pt #35 was discharged home on 10/10/2024 at 1420. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be updated every 7 days and signed by the Therapist, RN, and the Provider. Interview on 01/24/2025 at 1340 with Staff #9 revealed there was no Psychiatric Problem Sheet and no MTP update completed for Pt #35. Interview revealed that each short term goal on the Problem Sheets should have documentation of the date the goal was achieved or the goal should be documented as discontinued on the date of discharge. 3. Closed medical record review on 01/15/2025 for Patient #33 (Pt) revealed a 47-year-old female admitted to the hospital on 09/26/2024 at 2209 with a diagnosis of schizophrenia. Review of the Nurse Note on 09/29/2024 at 1800 revealed, “This patient came to the Nurses station about 1800 ... told Charge RN (Registered Nurse) and LPN (Licensed Practical Nurse) that the male patient that she was sitting by on Sat (Saturday) 9/28/2024 in the day room ... made sexual advances towards her ...” Review of the MTP, initiated on 09/27/2024 revealed, “Problem #1: SI (Suicidal Ideation- thoughts of suicide) ... Problem #2: AVH (auditory and visual hallucinations) ... Problem A: Asthma ...” Review of the Medical Problem Sheet failed to reveal a target date or if Pt #33’s goals were achieved for the problem of asthma. Review of the medical record failed to reveal documentation of a Behavior Management Plan or Individual Problem Sheets for SI and AVH during Pt #33’s admission (5 days after the MTP was initiated). Pt #33 was discharged home on 10/02/2024 at 2254. Interview on 01/24/2025 at 1340 with Staff #9 revealed there were no Psychiatric Problem Sheets completed for Pt #33. Interview revealed the MTP should have been updated after an event occurred if the problem was not previously included in the MTP. Interview revealed a Behavior Management Plan should have been completed within 24 hours of the event as part of the treatment plan. Interview revealed that each short term goal on the Problem Sheets should have documentation of the date the goal was achieved or the goal should be documented as discontinued on the date of discharge. 4. Closed medical record review on 01/21/2025 for Patient #52 (Pt) revealed a 26-year-old male admitted to the hospital on 01/05/2025 at 1649 with a diagnosis of bipolar disorder (a condition that causes extreme mood swings). Review of the Individual Problem Sheet failed to reveal documentation of the date Pt #52’s goals were achieved or discontinued. Pt #52 was discharged home on 01/15/2025 at 1016. Interview on 01/24/2025 at 1340 with Staff #9 revealed that each short term goal on the Problem Sheets should have documentation of the date the goal was achieved or the goal should be documented as discontinued on the date of discharge. 47421 5. Open medical record review of Patient #54 revealed a 36-year-old female involuntarily committed on 01/01/2025 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 01/05/2025 (4 days after admission). Review of the updated MTP revealed it was updated and signed 01/17/2025 (12 days after initial MTP). Record review revealed the patient was discharged 01/17/2025. Record review revealed the MTP was not completed within 72 hours and the updated MTP was not updated every 7 days per the facility policy. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be completed within 72 hours and updated at a minimum of every 7 days after initial completion. 6. Closed medical record review of Patient #59 revealed a 39-year-old male involuntarily committed on 10/03/2024 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 10/07/2024 (4 days after admission). Record review revealed the patient was discharged 10/10/2024. Record review revealed the MTP was not completed within 72 hours per the facility policy. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be completed within 72 hours. 7. Closed medical record review of Patient #44 revealed a 27-year-old female involuntarily committed on 10/04/2024 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 10/08/2024 (4 days after admission). Record review revealed the patient was discharged 10/09/2024. Record review revealed the MTP was not completed within 72 hours per the facility policy. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be completed within 72 hours. 8. Closed medical record review of Patient #46 revealed a 22-year-old male involuntarily committed on 09/30/2024 for psychosis. Review of the Master Treatment Plan (MTP) revealed a completion date of 10/03/2024. Record review revealed the patient was discharged 10/16/2024. Record review did not reveal an updated MTP (due 10/10/2024). Record review revealed the MTP was not updated every 7 days per the facility policy. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be updated at a minimum of every 7 days after initial completion. 26622 9. Closed medical record review on 01/09/2025 for Patient #19 revealed a 14-year-old female voluntary admitted to the facility on 12/17/2024 at 1813 with a diagnosis of Major Depressive Disorder and suicidal ideations. Review of the medical record revealed no evidence of an initial Master Treatment Plan (MTP) documented by the facility staff. Patient #19 was discharged to home with family on 12/23/2024 at 2000. Interview on 01/23/2025 at 1150 with Staff #8 revealed that the initial master treatment plan should be completed within 72 hours of admission and updated every seven days. 34065 10. Open medical record review on 01/15/2025 of Patient #40 revealed a 42-year-old female admitted on 01/02/2025 at 1410 with a diagnosis of Bipolar disorder (a condition that causes extreme mood swings) and unspecified psychosis not due to substance abuse. Review revealed Patient #40 had not slept in 4 days and had paranoid (suspicious), anxious (worried) and disorganized thoughts. Review of the medical record revealed a blank Interdisciplinary MTP (Master Treatment Plan). Patient #40 remained as an inpatient at the facility on 01/17/2025. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should have been completed within 72 hours of admission and signed by the Therapist, RN (Registered Nurse), and the Provider. 11. Closed medical record review on 01/13/2025 of Patient #24 revealed a 44 year-old female involuntarily committed on 09/30/2024 for psychosis. Review of the MTP revealed only facility signatures on 10/2/2024 and 10/4/2024 with the remaining portions of the MTP blank. Record review revealed the patient was discharged 10/11/2024. Record review did not reveal a completed MTP. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be initiated within 72 hours and updated at a minimum of every 7 days after initial completion. 12. Closed medical record review on 01/14/2025 of Patient #26 revealed a 60 year old male voluntarily admitted on 07/08/2024 for Bipolar disorder with suicidal ideations (thoughts) with a plan to electrocute himself. Review revealed no MTP in Patient #26’s medical record. Patient #26 was discharged on 07/14/2025. Interview on 01/16/2025 at 1200 with Staff #9 revealed Patient #26 MTP could not be located. Interview revealed policy was not followed for a MTP to be initiated within 72 hours. 50318 13. Closed medical record review on 01/09/2025 for Pt #10 revealed a 27-year-old patient who was involuntarily committed on 10/25/2024 with a diagnosis of schizophrenia (a disorder that affects a person’s ability to think, feel, and behave) with aggressive behaviors and homicidal ideations (HI - harming others). The Interdisciplinary Master Treatment Plan (MTP) was signed by the Psychiatrist, Therapist, Nurse, and Pt #10 on 10/28/2024. MTP Problem #1 was listed as HI with an update due on 11/04/2024. Pt #10 was discharged on 11/05/2024. Review failed to reveal an update to the MTP or a Behavior Management Plan (BMP). Review also failed to reveal evidence of a discussion with Pt #10’s legal guardian regarding the MTP. Interview on 01/10/2025 at 1014 with Staff #8 revealed Pt #10’s MTP should have been updated on 11/04/2024 even if he was discharged the next day. Staff #8 revealed Staff #35 was in touch with Pt #10’s legal guardian and might not have gone back in the medical record to sign the guardian’s acknowledgment of the MTP. Staff #8 acknowledged the MTP should have been updated for aggression due to Pt #10’s behavior while at the facility, and Staff #8 would have expected to see a BMP as well. 14. Closed medical record review on 01/14/2025 for Pt #39 revealed a 43-year-old patient who was involuntarily committed on 10/05/2024 with a diagnosis of schizoaffective disorder (a disorder that affects a person’s ability to think, feel, and behave) and antisocial personality disorder (a disorder characterized by impulsive and irresponsible behavior). The MTP was signed by the Psychiatrist, Therapist, Nurse, and Pt #39 on 10/08/2024. MTP Problem #1 was listed as AH/VH (auditory/visual hallucinations), and MTP Problem #2 was listed as substance use, with an update due on 10/13/2024. MTP Psychiatric Problem Sheets initially listed 10/13/2024 as the target date for weekly updates, but this date was marked out and handwritten as 10/20/2024 instead. A MTP update was signed by the Psychiatrist on 10/17/2024, the Nurse on 10/18/2024, and the Therapist, with no date listed for the Therapist’s signature (9 days after the MTP was initiated); the next update due was listed as 10/20/2024. An additional problem sheet for aggression requiring use of chemical restraint was created on 10/28/2024. Pt #39 was discharged to a shelter on 11/02/2024 at 1100. Record review failed to reveal evidence of a MTP update following the 10/17/2024 update during Pt #39’s admission (16 days after the first update) and failed to reveal evidence of a BMP. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be updated at a minimum of every 7 days after initial completion. Interview on 01/24/2024 at 1419 with Staff #70 revealed MTPs are based off what the issue was from admission or the Provider’s History and Psychiatric Evaluation of the patient. Staff #70 revealed the MTP updates would focus on these problems and would not add anything else to the problem sheet(s). Staff #70 was not aware of a BMP being completed. 51294 15. Open medical record review on 01/08/2025 for Patient #12 revealed a 15-year-old female admitted to the facility on 08/09/2024 with severe psychosis (disconnection with reality) and selective mutism (inability or unwillingness to speak) refractory (resistant) to medication treatment. Review of the medical record revealed that there was no Master Treatment Plan (MTP) found in the medical record. Patient #12 was discharged on 01/10/2025. Interview on 01/24/2025 at 0905 with Staff #53 revealed that in regard to Pt #12, “I checked and there is no Master Treatment Plan or problem sheets”. She further stated that all six charts (belonging to Patient #12) were reviewed and no MTP was found. 16. Closed medical record review on 01/14/2025 for Pt #25 revealed a 27-year-old male admitted to the facility on 09/13/2024 for psychosis and suicidal ideation (thoughts to hurt self) with a plan. Review of the medical record revealed there was no MTP or MTP updates found in the medical record. Patient #25 was discharged on 10/03/24. Interview on 01/23/2025 at 1235 with Staff #52 revealed that in regard to Pt #25, in regard to absence of MTP in the medical record, “It wouldn’t surprise me if it’s not there, we are extremely short staffed”. Staff #52 further stated that for Patient #52, MTP “should have been done by 09/16/2024, it was 4 days out of compliance.” The chart was reviewed by Staff #52 were reviewed and no MTP was found. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no MTP was found in the medical records for Patient #25. 17. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 as an IVC (Involunary Commitment) for aggression and suicidal and homicidal (thoughts to hurt others) ideation with a plan. Review of the medical record revealed there was no MTP found in the medical record. Patient #28 was discharged on 12/14/24. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no MTP was found in the medical records for Patient #28. 18. Closed medical record review on 01/21/2025 for Pt #31 revealed a 31-year-old male admitted to the facility on 08/14/2024 as an IVC for hallucinations (sensory experiences in the absence of an external stimuli) and suicidal ideation. Review of the medical record revealed there was no MTP found in the medical record. Patient #31 was discharged on 08/20/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no MTP was found in the medical records for Patient #31. 19. Closed medical record review on 01/14/2025 for Pt #14 revealed an 11-year-old male admitted to the facility on 12/19/2024 with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed there was no MTP were found in the medical record. Patient #14 was discharged on 12/24/2024 and would not have required a MTP update per policy. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no MTP was found in the medical records for Patient #14. 16369 20.. Open medical record review on 01/23/2025 for Patient #68 revealed a 46-year-old female involuntarily admitted to the facility on 01/18/2025 at 1813 with a diagnosis of bipolar disorder, manic and suicidal ideations with a plan. Review of the medical record revealed no evidence of an initial Master Treatment Plan (MTP) documented by the facility staff. Patient #68 was discharged home with family on 01/24/2025. Interview on 01/23/2025 at 1150 with Staff #8 revealed that the initial master treatment plan should be completed within 72 hours of admission and updated every seven days. Interview on 01/27/2025 at 1615 with Staff #84 revealed the therapist had started working at the hospital three weeks ago and just picked up a case load last week. Thee staff member confirmed there was no MTP found for Patient #68. 21. Closed medical record review on 01/10/2025 for Patient #16 revealed a 67-year-old male involuntarily admitted to the facility on 06/18/2024 with a diagnosis of schizophrenia, paranoid type and depression. Review of the medical record revealed no evidence of an initial Master Treatment Plan (MTP) documented by the facility staff. Patient #16 was discharged to an assisted living facility on 08/16/2024 (28 days after admission). Review revealed no MTP updates were found in the medical record. Interview on 01/10/2024 at 1315 with Staff #8 revealed that she thought a MTP had been completed, but no documentation could be found of a MTP for Patient #16. Interview on 01/23/2025 at 1150 with Staff #8 revealed that the initial master treatment plan should be completed within 72 hours of admission and updated every seven days. Interview on 01/20/2024 at 0900 with Staff #20 revealed there was no MTP available for Patient #16.”

“Treatment Plan - Goals CFR(s): [The written plan must include] Short-term and long range goals; This Standard is not met as evidenced by: 51294 Based on review of hospital policies, medical records and staff interviews, hospital staff failed to ensure short-term and long-range goals were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #38). The findings include: Review on 01/23/2025 of hospital policy “Interdisciplinary Patient-Centered Care Planning,” last reviewed on 04/2024, revealed, “...Developing the Treatment Plan...4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan...The treatment team will complete the MTP (Master Treatment Plan) including:...b. Completion of Individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem, specific behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention...Interdisciplinary Treatment Plan Update...1....The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum of every (7) seven days after the completion of the Master Treatment Plan...The following would be cause for conducting a review of the plan and developing a revision:...A new impairment/problem...2.... a. ...Once a goal has been resolved, the date will be identified on the treatment plan...c. Staff members, upon discharge, shall either document on remaining goals the date if resolved or ‘ongoing’ meaning that the problem has not yet been resolved...” 1. Open medical record review on 01/08/2025 for Patient #12 revealed a 15-year-old female admitted to the facility on 08/09/2024 with severe psychosis (disconnection with reality) and selective mutism (inability or unwillingness to speak) refractory (resistant) to medication treatment. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #12 was discharged on 01/10/2025. Interview on 01/24/2025 at 0905 with Staff #53 revealed that in regard to Pt #12, “I checked and there is no Master Treatment Plan or problem sheets”. She further stated that all six charts were reviewed and no MTP was found. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #12. 2. Closed medical record review on 01/21/2025 for Pt #31 revealed a 31-year-old male admitted to the facility on 08/14/2024 under Involuntary Commitment (IVC) for hallucinations (sensory experiences in the absence of an external stimuli) and suicidal (thoughts to harm self) ideation. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #31 was discharged on 08/20/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #31. 3. Closed medical record review on 01/2/2025 for Pt #32 revealed a 42-year-old male admitted to the facility on 06/29/2024 under IVC for psychosis and suicidal and homicidal (thoughts to harm others) ideation. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #32 was discharged on 07/25/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #32. 4. Closed medical record review on 01/14/2025 for Pt #25 revealed a 27-year-old male admitted to the facility on 09/13/2024 for psychosis and suicidal ideation with a plan. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #25 was discharged on 10/03/2024. Interview on 01/23/2025 at 1235 with Staff #52 revealed that in regard to Pt #25, in regard to absence of MTP and problem sheet in the medical record, “It wouldn’t surprise me if it’s not there, we are extremely short staffed”. Staff #52 further stated that for Patient #52, MTP (and problem sheet) “should have been done by 09/16/2024, it was 4 days out of compliance.” The chart was reviewed by Staff #52 were reviewed and no MTP or problem sheet was found. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #25. 5. Closed medical record review on 01/15/2025 for Patient #29 revealed a 17-year-old female admitted to the facility on 12/09/2024 as an IVC for depression, self-harm and suicidal ideation without a plan. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #29 was discharged on 12/24/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #29. 6. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #28 was discharged on 12/14/24. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #28. 7. Closed medical record review on 01/15/2025 for Pt #14 revealed a 15-year-old male admitted to the facility on 12/19/2024 under IVC with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #14 was discharged on 12/24/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #14. 40299 8. Closed medical record review on 01/14/2025 for Pt #38 revealed a 28-year-old male admitted to the facility on 08/07/2024 under IVC for paranoia (irrational and persistent belief that others are intentionally harming, deceiving, or persecuting you) and delusions (strong, false belief someone holds onto even when there’s clear evidence showing it’s not true). Review of the medical record revealed the MTP was developed on 08/09/2024 (day of admission). Pt was #38 discharged home on 08/16/2024. Review of the treatment plan problem sheets revealed no documentation of the date Pt#38’s goals were achieved or discontinued. Interview on 01/24/2025 at 1340 with Staff #9 revealed that each short term goal on the Problem Sheets should have documentation of the date the goal was achieved or the goal should be documented as discontinued on the date of discharge.”

“Treatment Plan - Modalities CFR(s): [The written plan must include] The specific treatment modalities utilized; This Standard is not met as evidenced by: 51294 Based on review of hospital policies, medical records and staff interviews, hospital staff failed to ensure a Master Treatment Plan with specific treatment modalities were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #60). The findings include: Review on 01/23/2025 of hospital policy “Interdisciplinary Patient-Centered Care Planning,” last reviewed on 04/2024, revealed, “...Developing the Treatment Plan...4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan...The treatment team will complete the MTP (Master Treatment Plan) including:...b. Completion of Individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem, specific behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention...Interdisciplinary Treatment Plan Update...1....The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum of every (7) seven days after the completion of the Master Treatment Plan...The following would be cause for conducting a review of the plan and developing a revision:...A new impairment/problem...2.... a. ...Once a goal has been resolved, the date will be identified on the treatment plan...c. Staff members, upon discharge, shall either document on remaining goals the date if resolved or ‘ongoing’ meaning that the problem has not yet been resolved...” Review on 01/24/2025 of hospital policy “Documentation Requirements In The Medical Record,” last revised 11/2023, revealed, “...Treatment Plan...14. Behavior management plans shall be written as part of the Treatment Plan ...” 1. Open medical record review on 01/14/2025 for Patient #12 revealed a 15-year-old female admitted to the facility on 08/09/2024 with severe psychosis (disconnection with reality) and selective mutism (inability or unwillingness to speak) refractory (resistant) to medication treatment. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #12 was discharged on 01/10/2025. Interview on 01/24/2025 at 0905 with Staff #53 revealed that in regard to Pt #12, “I checked and there is no Master Treatment Plan or problem sheets”. She further stated that all six charts were reviewed and no MTP was found. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included specific treatment modalities related to the MTP were found in the medical records for Patient #12. 2. Closed medical record review on 01/21/2025 for Pt #31 revealed a 31-year-old male admitted to the facility on 08/14/2024 under Involuntary Commitment (IVC) for hallucinations (sensory experiences in the absence of an external stimuli) and suicidal (thoughts to harm self) ideation. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #31 was discharged on 08/20/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included specific treatment modalities related to the MTP were found in the medical records for Patient #31. 3. Closed medical record review on 01/2/2025 for Pt #32 revealed a 42-year-old male admitted to the facility on 06/29/2024 under IVC for psychosis and suicidal and homicidal ideation. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #32 was discharged on 07/25/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included specific treatment modalities related to the MTP were found in the medical records for Patient #32. 4. Closed medical record review on 01/14/2025 for Pt #25 revealed a 27-year-old male admitted to the facility on 09/13/2024 for psychosis and suicidal ideation with a plan. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #25 was discharged on 10/03/2024. Interview on 01/23/2025 at 1235 with Staff #52 revealed that in regard to Pt #25, in regard to absence of MTP and problem sheet in the medical record, “It wouldn’t surprise me if it’s not there, we are extremely short staffed”. Staff #52 further stated that for Patient #52, MTP (and problem sheet) “should have been done by 09/16/2024, it was 4 days out of compliance.” The chart was reviewed by Staff #52 were reviewed and no MTP or problem sheet was found. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included specific treatment modalities related to the MTP were found in the medical records for the following patients: Pt #12, Pt #31, Pt #32, Pt #25, Pt #29, Pt #28 and Pt #14). 5. Closed medical record review on 01/15/2025 for Pt #29 revealed a 17-year-old female admitted to the facility on 12/09/2024 as an IVC for depression, self-harm and suicidal ideation without a plan. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #29 was discharged on 12/24/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included specific treatment modalities related to the MTP were found in the medical records for the following patients: Pt #12, Pt #31, Pt #32, Pt #25, Pt #29, Pt #28 and Pt #14). 6. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #28 was discharged on 12/14/24. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included specific treatment modalities related to the MTP were found in the medical records for Patient #28. 7. Closed medical record review on 01/15/2025 for Pt #14 revealed a 15-year-old male admitted to the facility on 12/19/2024 under IVC with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #14 was discharged on 12/24/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included specific treatment modalities related to the MTP were found in the medical records for Patient #14. 16369 8. Closed medical record review on 01/22/2025 for Pt #60 revealed a 43-year-old male admitted to the facility on 10/10/2024 under IVC (involuntary commitment) with schizophrenia and assaultive behavior. Record review revealed the patient was admitted due to setting a homeless person’s tent on fire and breaking into a business prior to arrival. Review of the Discharge Summary signed 12/05/2024 by a psychiatrist revealed the patient was disruptive on the unit causing him to receive medication for assaultive behaviors on 10/14/2024. Review of the MTP signed and dated by a therapist on 10/17/2024 recorded three problem areas identified that included psychosis, aggression and homelessness. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #60 was discharged on 10/15/2024. Interview on 01/24/2025 at 1205 with Staff #9 revealed no modalities were found. The staff member stated there was no evidence that the specific treatment modalities related to the MTP were documented for Patient #60.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 51294 Based on hospital policy review, medical record reviews, and staff interviews, the hospital failed to ensure treatment team responsibilities were completed for 11 of 72 medical records reviewed. (Pt #12, #31, #32, #25, #29, #28, #14, #59, #54, #38, and #9). The findings include: Review of hospital policy titled “Interdisciplinary Patient-Centered Care Planning” last reviewed 04/2024, revealed “ ...4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan including:...b. Completion of Individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem, specific behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention ... 5. The patient/family and/or guardian is to sign the treatment plan to indicate their agreement with and participation in development of the plan ...” 1. Open medical record review on 01/08/2025 for Patient #12 revealed a 15-year-old female admitted to the facility on 08/09/2024 with severe psychosis (disconnection with reality) and selective mutism (inability or unwillingness to speak) refractory (resistant) to medication treatment. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #12 was discharged on 01/10/2025. Interview on 01/24/2025 at 0905 with Staff #53 revealed that in regard to Pt #12, “I checked and there is no Master Treatment Plan or problem sheets”. She further stated that all six charts were reviewed and no MTP or problem sheets were found. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included team responsibilities related to the MTP were found in the medical records for Patient #12. 2. Closed medical record review on 01/21/2025 for Pt #31 revealed a 31-year-old male admitted to the facility on 08/14/2024 under Involuntary commitment (IVC) for hallucinations (sensory experiences in the absence of an external stimuli) and suicidal (thoughts to harm self) ideation. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #31 was discharged on 08/20/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included team responsibilities related to the MTP were found in the medical records for Patient #31. 3. Closed medical record review on 01/2/2025 for Pt #32 revealed a 42-year-old male admitted to the facility on 06/29/2024 under IVC for psychosis and suicidal and homicidal ideation. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #32 was discharged on 07/25/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included team responsibilities related to the MTP were found in the medical records for Patient #32. 4. Closed medical record review on 01/14/2025 for Pt #25 revealed a 27-year-old male admitted to the facility on 09/13/2024 for psychosis and suicidal ideation with a plan. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #25 was discharged on 10/03/2024. Interview on 01/23/2025 at 1235 with Staff #52 revealed that in regard to Pt #25, in regard to absence of MTP and problem sheet in the medical record, “It wouldn’t surprise me if it’s not there, we are extremely short staffed”. Staff #52 further stated that for Patient #52, MTP (and problem sheet) “should have been done by 09/16/2024, it was 4 days out of compliance.” The chart was reviewed by Staff #52 were reviewed and no MTP or problem sheet was found. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included team responsibilities related to the MTP were found in the medical records for Patient #25. 5. Closed medical record review on 01/15/2025 for Pt #29 revealed a 17-year-old female admitted to the facility on 12/09/2024 as an IVC for depression, self-harm and suicidal ideation without a plan. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #29 was discharged on 12/24/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included team responsibilities related to the MTP were found in the medical records for Patient #29. 6. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #28 was discharged on 12/14/24. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included team responsibilities related to the MTP were found in the medical records for Patient #28. 7. Closed medical record review on 01/15/2025 for Pt #14 revealed a 15-year-old male admitted to the facility on 12/19/2024 under IVC with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #14 was discharged on 12/24/2024. Interview on 01/24/2025 at 1340 with Staff #9 revealed that no “problem sheet” that would have included team responsibilities related to the MTP were found in the medical records for Patient #14. 47421 8. Closed medical record review of Patient #59 revealed a 39-year-old male involuntarily committed on 10/03/2024 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 10/07/2024. Record review revealed the patient was discharged 10/10/2024. Review of the MTP revealed no printed name or signature of the treatment team nurse and no patient signature was documented. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be completed and signed within 72 hours by the treatment team and patient. Interview revealed the MTP should be signed by the Physician, Nurse, and Social Worker. 9. Open medical record review of Patient #54 revealed a 36-year-old female involuntarily committed on 01/01/2025 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 01/05/2025. Review of the updated MTP revealed it was updated and signed 01/17/2025. Record review revealed the patient was discharged 01/17/2025. Review of the MTP revealed the nurse signed and dated the MTP on 01/17/2025 (12 days after initial MTP). Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be completed and signed within 72 hours by the treatment team. 40299 10. Closed medical record review on 01/14/2025 for Pt #38 revealed a 28-year-old male admitted to the facility on 08/07/2024 under IVC for paranoia (irrational and persistent belief that others are intentionally harming, deceiving, or persecuting you) and delusions (strong, false belief someone holds onto even when there’s clear evidence showing its not true) and discharged on 08/16/2024. The Interdisciplinary Master Treatment Plan (MTP) revealed it was signed by the Therapist and the Nurse Practitioner on 08/09/2024. The MTP failed to include documentation of the Psychiatrist and Nurse signatures/involvement. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should have been completed within 72 hours of admission and signed by the Therapist, Registered Nurse (RN), and the Provider. 50318 11. Closed medical record review on 01/09/2025 for Pt #9 revealed a 32-year-old patient who was involuntarily committed on 05/11/2024 with a diagnosis of schizophrenia (a disorder that affects a person’s ability to think, feel, and behave) and increased aggression (violent attacking behavior or attitude toward another person) with staff at his group home. The Interdisciplinary Master Treatment Plan (MTP) was signed by the Therapist, Nurse, and the Nurse Practitioner on 05/14/2024. Pt #9 was discharged to a shelter on 05/20/2024. Review of the MTP revealed no patient or guardian signature was documented. Review failed to reveal a psychiatric problem sheet with the team responsibilities related to the MTP. Interview on 01/14/2025 at 1612 with Staff #53 revealed there was no MTP problem sheet with responsibilities for Pt #9. Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP, including the problem sheet, should be completed and signed within 72 hours by the treatment team and the patient.”

“Document Therapeutic Efforts CFR(s): The treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included. This Standard is not met as evidenced by: 50111 Based on review of hospital policies, medical records and staff interviews, hospital staff failed to document daily group therapy for 4 of 72 medical records reviewed (Pt #52, #35, #34, #33). The findings include: Review on 01/28/2025 of hospital policy “Active and Individualized Treatment,” last reviewed 04/2024, revealed, “... Active treatment services provided must be: ... Provided 7 days a week ... Each group leader assigned to conduct a group session identified in the treatment plan is responsible for ... documenting the group per facility policy in each patient’s medical record ...” Review on 01/24/2025 of hospital policy “Documentation Requirements In The Medical Record,” last revised 11/2023, revealed, “... Group Notes ... 1. Group notes shall be documented in the Progress Note section within eight (8) hours of the group session ... “ 1. Closed medical record review on 01/21/2025 for Patient #52 (Pt) revealed a 26-year-old male admitted to the hospital on 01/05/2025 at 1649 with a diagnosis of bipolar disorder (a condition that causes extreme mood swings). Record review failed to reveal notes for Psychoeducation and Nurse Group on 01/06/2025, 01/07/2025, and 01/08/2025, 01/10/2025, and 01/14/2025. Record review failed to reveal notes for Activity Therapy, Psychoeducation and Nurse Group on 01/09/2025. Review failed to reveal notes for Activity Therapy, Psychoeducation and Process Group on 01/12/2025. Record review failed to reveal notes for Activity Therapy, Psychoeducation and Nurse Group on 01/13/2025. Pt #52 was discharged home on 01/15/2025 at 1016. Interview on 01/21/2025 at 1506 with Staff #17 revealed group therapy was sometimes not completed as scheduled depending on what was occurring on the unit at that time. Interview revealed Nurse Group was sometimes not completed if there were admissions during the time Nurse Group was scheduled. Interview revealed there should be a Group Therapy Note in the patients’ medical records for all completed group therapies. Interview on 01/24/2025 at 1437 with Staff #25 revealed it was difficult to get group therapy done at times because more staff was needed. Interview on 01/24/2025 at 1130 with Staff #9 revealed there should be Group Therapy Notes for Activity Therapy, Process Group, Psychoeducation, and Nurse Group in each patient’s medical record daily. 2. Closed medical record review on 01/15/2025 for Patient #35 (Pt) revealed a 44-year-old male admitted to the hospital on 09/25/2024 at 2308 with a diagnosis of schizophrenia (a disorder that affects a person’s ability to think, feel, and behave clearly). Record review failed to reveal notes for Process Group, Psychoeducation, and Nurse Group on 09/26/2024, 09/28/2024, 09/30/2024, 10/02/2024, 10/03/2024, 10,04/2024, 10/05/2024, 10/08/2024, and 10/09/2024. Review failed to reveal notes for Activity Therapy, Process Group, and Nurse Group on 10/07/2024. Review failed to reveal any Group Therapy Notes on 09/27/2024, 09/29/2024, 10/01/2024, and on 10/06/2024. Pt #35 was discharged home on 10/10/2024 at 1420. Interview on 01/21/2025 at 1506 with Staff #17 revealed group therapy was sometimes not completed as scheduled depending on what was occurring on the unit at that time. Interview revealed Nurse Group was sometimes not completed if there were admissions during the time Nurse Group was scheduled. Interview revealed there should be a Group Therapy Note in the patients’ medical records for all completed group therapies. Interview on 01/24/2025 at 1437 with Staff #25 revealed it was difficult to get group therapy done at times because more staff was needed. Interview on 01/24/2025 at 1130 with Staff #9 revealed there should be Group Therapy Notes for Activity Therapy, Process Group, Psychoeducation, and Nurse Group in each patient’s medical record daily. 3. Closed medical record review on 01/15/2025 for Patient #34 (Pt) revealed a 27-year-old male admitted to the hospital on Saturday, 09/28/2024 at 1235 with a diagnosis of substance abuse and major depressive disorder. Record review failed to reveal any Group Therapy Notes for Pt #34 on 09/28/2024 and 09/29/2024. Review failed to reveal notes for Psychoeducation Group and Nurse Group on 09/30/2024. Review failed to reveal any Group Therapy Notes on 10/01/2024. Review failed to reveal notes for Activity Therapy, Psychoeducation Group and Nurse Group on 10/02/2024. Review failed to reveal any Group Therapy Notes on 10/03/2024. Pt #34 was discharged home on 10/04/2024 at 1117. Interview on 01/21/2025 at 1506 with Staff #17 revealed group therapy was sometimes not completed as scheduled depending on what was occurring on the unit at that time. Interview revealed Nurse Group was sometimes not completed if there were admissions during the time Nurse Group was scheduled. Interview revealed there should be a Group Therapy Note in the patients’ medical records for all completed group therapies. Interview on 01/24/2025 at 1437 with Staff #25 revealed it was difficult to get group therapy done at times because more staff was needed. Interview on 01/24/2025 at 1130 with Staff #9 revealed there should be Group Therapy Notes for Activity Therapy, Process Group, Psychoeducation, and Nurse Group in each patient’s medical record daily. 4. Closed medical record review on 01/15/2025 for Patient #33 (Pt) revealed a 47-year-old female admitted to the hospital on 09/26/2024 at 2209 with a diagnosis of schizophrenia. Record review failed to reveal notes for Process Group, Psychoeducation, and Nurse Group on 09/27/2024, 09/28/2024, and on 09/30/2024. Review failed to reveal any Group Therapy Notes on 09/29/2024. On 10/01/2024, review failed to reveal notes for Process Group and Nurse Group. On 10/02/2024, review failed to reveal notes for Activity Therapy, Process Group, and Psychoeducation. Pt #33 was discharged home on 10/02/2024 at 2254. Interview on 01/21/2025 at 1506 with Staff #17 revealed group therapy was sometimes not completed as scheduled depending on what was occurring on the unit at that time. Interview revealed Nurse Group was sometimes not completed if there were admissions during the time Nurse Group was scheduled. Interview revealed there should be a Group Therapy Note in the patients’ medical records for all completed group therapies. Interview on 01/24/2025 at 1437 with Staff #25 revealed it was difficult to get group therapy done at times because more staff was needed. Interview on 01/24/2025 at 1130 with Staff #9 revealed there should be Group Therapy Notes for Activity Therapy, Process Group, Psychoeducation, and Nurse Group in each patient’s medical record daily.”

“Recording Progress Notes CFR(s): Standard: Recording Progress Progress notes must be recorded by the physician(s), psychologists, or other licensed independent practitioner(s) responsible for the care of the patient as specified in §482.12(c); nurse, social worker and, when appropriate, others significantly involved in active treatment modalities. The frequency of progress notes is determined by the condition of the patient but must be recorded at least weekly for the first 2 months and at least once a month thereafter and must contain recommendations for revisions in the treatment plan as indicated as well as precise assessment of the patient’s progress in accordance with the original or revised treatment plan. This Standard is not met as evidenced by: 50111 Based on review of hospital policy, medical records and staff interviews, hospital staff failed to ensure Social Services Progress Notes were completed for 11 of 72 medical records reviewed (Pt #34, #35, #54, #9, #10, #30, #39, #67, #25, #28, #16). The findings include: Review on 01/24/2025 of hospital policy “Documentation Requirements In The Medical Record,” last revised 11/2023, revealed, “... Social Services .... 2. The initial Social Services note shall be made within seventy-two hours (72) of admission ... 4. Each problem addressed by Social Services staff on the Master Treatment Plan shall be addressed in the progress note at least weekly ...” 1. Closed medical record review on 01/15/2025 for Patient #34 (Pt) revealed a 27-year-old male admitted to the hospital on 09/28/2024 at 1235 with a diagnosis of substance abuse and major depressive disorder. Record review failed to reveal Social Services Progress Notes during Pt #34’s admission (6 days). Pt #34 was discharged home on 10/04/2024 at 1117. Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days. 2. Closed medical record review on 01/15/2025 for Patient #35 (Pt) revealed a 44-year-old male admitted to the hospital on 09/25/2024 at 2308 with a diagnosis of schizophrenia (a disorder that affects a person’s ability to think, feel, and behave clearly). Record review revealed a Social Services Progress Note was completed on 09/26/2024. Review failed to reveal Social Services Progress Notes after 09/26/2024 until discharge (14 days). Pt #35 was discharged home on 10/10/2024 at 1420. Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days. 47421 3. Open medical record review of Patient #54 revealed a 36-year-old female involuntarily committed on 01/01/2025 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 01/05/2025. Review of the updated MTP revealed it was updated and signed 01/17/2025. Record review revealed the patient was discharged 01/17/2025. Record review revealed no Social Services progress notes were documented. Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed at a minimum of every 7 days and as needed. 50318 4. Closed medical record review on 01/09/2025 for Pt #9 revealed a 32-year-old patient who was involuntarily committed on 05/11/2024 with a diagnosis of schizophrenia (a disorder that affects a person’s ability to think, feel, and behave) and increased aggression (violent attacking behavior or attitude toward another person) with staff at his group home. Record review revealed a Social Services Progress Note was completed on 05/14/2024 at 1740, which noted Pt #9 would need social resources post-discharge for “housing and mental health.” Review failed to reveal Social Services Progress Notes after 05/14/2024 until discharge (6 days). Pt #9 was discharged to a shelter on 05/20/2024 (time not specified) with an outpatient follow-up appointment on 05/21/2024. Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days. 5. Closed medical record review on 01/09/2025 for Pt #10 revealed a 27-year-old patient who was involuntarily committed on 10/25/2024 with a diagnosis of schizophrenia, with aggressive behaviors and homicidal ideations (HI - harming others). Record review failed to reveal Social Services Progress Notes during Pt#10’s admission (11 days). Pt #10 was discharged on 11/05/2024. Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days. 6. Closed medical record review on 01/14/2025 for Pt #30 revealed a 14-year-old patient voluntarily admitted on 05/24/2024 for disruptive mood dysregulation (a disorder characterized with ongoing irritability, anger, and frequent, intense temper outbursts) and oppositional defiant disorder (a disorder characterized by uncooperative, defiant, and hostile behavior to authority figures). Record review revealed a Social Services Progress Note was completed on 05/27/2024. A second Social Services Progress Note was completed on 06/07/2024 (11 days later). Review failed to reveal Social Services Progress Notes after 06/07/2024 until discharge (41 days). Pt #30 was discharged home on 07/18/2024 at 1100 with a psychological evaluation scheduled at Facility C at 1300. Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days. 7. Closed medical record review on 01/14/2025 for Pt #39 revealed a 43-year-old patient who was involuntarily committed on 10/05/2024 with a diagnosis of schizoaffective disorder (a disorder that affects a person’s ability to think, feel, and behave) and antisocial personality disorder (a disorder characterized by impulsive and irresponsible behavior). Record review revealed a Social Services Progress Note was completed on 10/08/2024. A second Social Services Progress Note was completed on 10/15/2024. Two Social Services Progress Notes were completed on 10/22/2024. Review failed to reveal Social Services Progress Notes after 10/22/2024 until discharge (11 days). Pt #39 was discharged to a shelter on 11/02/2024 at 1100 with an outpatient follow-up appointment on 11/04/2024 at 1000. Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days. 8. Closed medical record review on 01/24/2025 for Pt #67 revealed a 43-year-old patient who was involuntarily committed on 10/29/2024 for severe, recurrent major depressive disorder (MDD - mental health disorder characterized by two or more weeks of feeling sad, low self-esteem, and loss of interest in normal activities), anxiety (tension and/or worried thoughts), suicidal ideations (SI - cause harm or death to one self), and HI. Record review failed to reveal Social Services Progress Notes during Pt #67’s admission (15 days). Pt #67 was discharged home on 11/13/2024. Interview on 01/10/2025 at 1014 with Staff #8 revealed Therapists should be writing a note for each therapy session and did not know why the Social Service Progress Notes were missing from Pt #10’s medical record. Follow-up Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed at a minimum of every 7 days and as needed. 51294 9. Closed medical record review on 01/14/2025 for Pt #25 revealed a 27-year-old male admitted to the facility on 09/13/2024 for psychosis and suicidal ideation with a plan. Review of the medical record revealed that the comprehensive clinical assessment was completed on 09/21/2024 (8 days after admission). There were no social work progress notes found in the medical record. Pt # 25 was discharged on 10/03/2025. Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days. 10. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that the comprehensive clinical assessment was found in the chart completely blank. There were no social work progress notes found in the medical record. Pt # 28 was discharged on 12/14/2024. Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days. 16369 11. Closed medical record review on 01/10/2025 for Patient #16 revealed a 67-year-old male involuntarily admitted to the facility on 06/18/2024 with a diagnosis of schizophrenia, paranoid type and depression. Review of the medical record revealed one Social Services Progress Note documented on 07/06/2024 documenting an attempt to gain collateral information regarding the patient’s legal guardian. Review of the record revealed no further Social Services Progress Notes were documented during the patient’s admission (28 days). Patient #16 was discharged to an assisted living facility on 08/16/2024 (28 days after admission). Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days.”

“Discharge Summary - Recommendations CFR(s): … and recommendations from appropriate services concerning follow-up or aftercare This Standard is not met as evidenced by: 16369 Based on review of hospital policy, medical records, and staff interviews, the hospital failed to ensure patients received follow up appointments and prescriptions prior to patients being discharged for 3 of 59 sampled closed medical records (Pt #60, #68, #36). The findings include: Review of the “Duties of Social Services Staff” policy reviewed 10, 2022 revealed, “... Social services staff coordinates discharge planning with internal and external staff and with patients. Social services staff implement discharge planning that includes facilitating placement of patients based on recommended level of care and making appointments for patients with providers. Review of a “Discharge Planning” policy last reviewed 10/2022 revealed, “Discharge planning begins the day of admission for all patients served by (hospital name). Discharge planning is discussed daily and at each Treatment Team Meeting for a patient. ... The Therapist/Case Manager is the responsible party for initiating, planning and working with the patient, the family, the Treatment Team members, and outside providers/agencies to develop the Discharge Plan. The Therapist/Case Manager discusses after care with the patient and guardian(s), in collaboration with community supports. The Therapist/Case Manager schedules after care appointments for patients ... Patients are expected to attend an aftercare appointment within 7 days from their discharge date, typically with a therapist. Patients who are prescribed psychotropic medications are expected to see a psychiatrist and/or primary care physician or therapist within 30 days from their discharge date. ... If an adult patient does not want the therapist to make the appointments, document it in a progress note. Tell the patient that he/she will need to have appointments before discharge. Talk to the attending psychiatrist about the issue. If no appointments have been made the day of discharge, tell the attending psychiatrist and follow any instructions. ...” 1. Closed medical record review on 01/22/2025 for Pt #60 revealed a 43-year-old male admitted to the facility on 10/10/2024 under IVC (involuntary commitment) with schizophrenia and assaultive behavior. Record review revealed the patient was admitted due to setting a homeless person’s tent on fire and breaking into a business prior to arrival. Patient #60 was discharged via taxi to a shelter located in Raleigh, NC on 10/15/2024. Review of the Discharge Summary signed by a psychiatrist on 12/01/2024 revealed discharge medications included Synthroid (medication for thyroid hormone replacement), lithium (mood stabilizer), Prilosec (medication for acid reflux), and Invega (antipsychotic medication). Review of the Discharge Medication Summary revealed Synthroid, lithium and Invega were e-prescribed to a pharmacy in Carroboro, NC (approximately 30 miles away from the patient’s shelter location). Interview on 01/24/2025 with Staff #85 revealed the patient had come from a shelter in Hillsboro, NC prior to arrival at the hospital and was working with an ACTT team. The staff member reported talking with the ACTT team who reported they had been trying to find the patient without success. The staff member stated that the ACTT team’s role was to help the patient with resources, finding medications, transport and appointments. The staff member reported that they discussed discharge plans and ACTT was going to pick up the patient at the time of discharge and take him to the shelter. The staff member reported the patient’s case was transferred to another therapist due to a change in units. The staff member stated a transfer sheet that included the patient’s discharge plan should have been completed when he was moved to another unit, but the staff member was unable to locate the transfer sheet in the patient’s medical record. Interview on 01/24/2025 at 1500 with Staff #86 revealed she was a Case Manager that reviewed the discharge information with the patient prior to discharge. The staff member stated she “helps the therapist” by getting information from the patient and reviews the discharge plans with the patient. She said she reviewed the placement and arranged a cab voucher and outpatient care plans with the patient. She stated the patient told her he had no outpatient provider so she chose a provider (different from the ACTT team that was involved with his care previously). The staff member stated the therapist would usually provide that information but “that unit (2 East) didn’t have a therapist for awhile.” The staff member stated she didn’t get any information that the patient came from a shelter in Chapel Hill and that he had ACTT team involved with his care. Telephone interview on 11/24/2025 at 1500 with Staff #87 revealed he didn’t remember the patient. The nurse revealed his role was to talk with the Nurse Practitioner (NP) and tell her where the patient got his prescriptions. He stated he would explain to the patient what his prescriptions are and where they were sent. Telephone interview on 01/27/2025 at 1055 with Staff #42 revealed she was the NP that e-prescribed the patient’s medication to a pharmacy in Carroboro, NC. Interview revealed the NP did not remember Patient #60. The NP stated she would normally ask the patient where he wanted his medication sent to. She stated that that information was usually discussed in treatment team meetings if there was a change in location. Staff #88 stated she didn’t know how the patient who was housing at a shelter in Raleigh, NC would be able to get his medication from a pharmacy in Carroboro, NC. The NP stated it was possibly a “communication missed.” 2. Open medical record review on 01/23/2025 for Patient #68 revealed a 46-year-old female involuntarily admitted to the facility on 01/18/2025 at 1813 with a diagnosis of bipolar disorder, manic and suicidal ideations with a plan. Patient #68 was discharged home via sheriff on 01/24/2025. Review of discharge paperwork signed by the patient and a therapist on 01/23/2025 at 1630 revealed no aftercare appointments arranged for therapy or psychiatric follow up care. Review of a therapy note dated 01/23/2025 at 1630 recorded, “Patient stated during d/c (discharge planning) she will find her own outpatient therapy services. ...” Interview on 01/27/2025 at 1615 with Staff #84 revealed the therapist had started working at the hospital three weeks ago and just picked up a case load last week. The staff member stated the patient wanted to get her own provider. The staff member stated the patient didn’t have any prior contacts and didn’t report having a psychiatrist. She stated the normal process is that she would call someone in her area and set up an appointment. The staff member stated, “That was the first time it happened (wanting to get her one appointment). I didn’t notify the provider. I didn’t contact her spouse. She transported via sheriff to (named) county.” Interview revealed the hospital policy was not followed. 40299 3. Closed medical record review on 01/23/2025 for Patient #36 revealed a 23-year-old male admitted to the hospital on 11/15/2024 at 1535 under IVC (involuntary commitment) for evaluation of suicide ideation, paranoid ideations and delusions. Patient #36 was discharged home on 11/26/2024. Review of the Discharge Medication Summary revealed Patient #36 was to continue taking Depakote (medication to treat bipolar disorder/mental health disorder), Invega Sustenna (medication to treat schizoaffective disorder/mental health disorder), Vistaril (medication to treat anxiety) and Inderal (medication to treat anxiety). Review revealed the Vistaril, Depakote, Inderal and Invega Sustenna were e-prescribed to Patient #36’s pharmacy on 11/26/2024 at 0859. The Discharge Medication Summary was signed Patient #36 and a Nurse on 11/26/2024 at 1600. Review of the Nurse note dated 11/26/2024 (not timed) revealed “Pt (patient) A&O x 3 (alert and oriented times three), stable at D/C (discharge). Escorted to reception for transport ...” Review of the e-prescription documentation revealed the Invega Sustenna, the Inderal, and the Vistaril was e-prescribed to Patient #36’s pharmacy on 11/27/2024 at 1531 and accepted by the pharmacy at 1532. The Depakote was e-prescribed on 11/27/2024 however there was an error and the pharmacy did not receive the e-prescription. The Depakote was e-prescribed an additional time and was not received due to an error. The Depakote was e-prescribed for the third time on 11/29/2024 at 1132 and accepted by the pharmacy at 1353. Review of the Service Desk tickets and communication provided on 01/16/2025 revealed there was a problem with e-prescription of Depakote DR 500 mg (milligrams) identified and a service ticket sent to the Service Desk on 07/26/2024 at 0957. There was a correction made on 08/08/2024 at 1039. There was email communication from the Director of Pharmacy to the Providers on 01/02/2025 at 1621 notifying of a problem discovered and requesting the Providers check all Depakote e-scripts for an error message as the e-scripts may not be sent properly to the pharmacy. There was a second ticket provided for the Depakote e-scripts submitted on 01/03/2025 at 0948 and corrected at 1142. Interview on 01/16/2025 at 1435 with Staff #67 revealed she had e-prescribed the medication Patient #36 was to continue taking at discharge to Patient #36’s pharmacy. Interview revealed there was a problem with the Depakote going through to the pharmacy. Staff #67 could not remember if someone had contacted the facility about the prescription or if she had noticed it had not going through and continued to try to send the e-prescription. Interview revealed the facility was aware there was a problem previously and thought it had been fixed, so when this e-prescription did not go through, Staff #67 felt it was the same problem already identified and continued to send the e-prescription. Interview revealed when a discharged patient or legal guardian calls back to the facility after the patient has been discharged, there is no documentation of this call nor what it was about. The interview revealed Staff #67 felt the problem with e-scribing of Depakote got fixed however it appears to have happened again. Interview revealed the facility was working to have a permanent fix for the problem with e-prescribing Depakote.”

“Psychological Services CFR(s): Standard: Psychological Services The hospital must provide or have available psychological services to meet the needs of the patients. This Standard is not met as evidenced by: 50318 Based on review of the facility’s psychologist contract, personnel file, medical record review, and staff interviews, the facility failed to provide psychological services for 1 of 1 sampled patients needing psychological testing and evaluation (Patient #30). The findings include: Review on 01/24/2025 of the Psychologist Service Agreement, effective April 2018, revealed, “... I. Obligations of Psychologist. A. Psychologist shall provide psychological evaluation and on-call services for Facility’s IVC (involuntarily committed) patients as needed and requested by Facility pursuant to a schedule agreed to by the parties ... D. Psychologist shall actively participate in Facility’s overall patient care evaluation program...” Review on 01/27/2025 of Staff #30’s personnel file revealed Staff #30 was initially appointed on 06/09/2003 with most recent reappointment on 06/26/2023. Staff #30 was privileged for adult, adolescent, and child psychological assessments. Closed medical record review on 01/14/2025 for Patient #30 (Pt) revealed a 14-year-old patient voluntarily admitted on 05/24/2024 for disruptive mood dysregulation (a disorder characterized with ongoing irritability, anger, and frequent, intense temper outbursts) and oppositional defiant disorder (a disorder characterized by uncooperative, defiant, and hostile behavior to authority figures). Pt #30 endorsed high risk behaviors including running away from home, was gone for eight days, and had been using marijuana. Comprehensive Clinical Assessment on 05/27/2024 revealed Pt #30’s family would like the Pt to go to a residential facility to assist with substance use and making the right decisions. Master Treatment Plan (MTP) completed on 05/27/2024 with verbal consent from Pt #30’s family noted the initial discharge disposition as alternative living arrangements. MTP update (MTPU) on 06/03/2024 revealed Pt #30’s family was involved with referrals, and the recommended discharge plan was PRTF (Psychiatric Residential Treatment Facility, a non-acute inpatient facility for patients with mental illness or substance abuse). Psychiatric Progress Note on 06/21/2024 revealed Pt #30 was not discharged as planned due to the bed being given away; the family did not sign the required papers and forms for placement, and Pt # 30 was unable to go to the facility. MTPU on 06/24/2024 listed barriers to discharge planning as pending placement, and the family did not feel safe for Pt #30 to return home. Psychiatric Progress Note on 06/24/2024 revealed Pt #30 stated her family found a place (out of state) for long-term placement, and Pt #30 was ready to go to placement when possible. MTPU on 07/01/2024 listed barriers to discharge planning as pending placement, and the family continued to believe Pt #30 would run away if the patient returned home. MTPU on 07/08/2024 listed barriers to discharge planning as referrals were denied, but the family was still concerned about Pt #30 returning home. Aftercare and Discharge Plan on 07/17/2024 revealed Pt #30 was to be discharged home with family on 07/18/2024. An aftercare appointment was made at Facility C for 07/18/2024 at 1300 for an additional evaluation the family had requested, with transportation designated as the (named) family. Discharge Summary on 07/18/2024 revealed Pt #30’s family requested residential referrals, but Pt #30 did not get accepted right away and two places were pending at the time of dictation. Pt #30 was discharged home on 07/18/2024 with the pending referrals to residential treatment. Record review revealed no psychological evaluation or testing was performed. Interview on 01/15/2025 at 0958 with Staff #47 revealed Staff #47 recalled Pt #30, who had been accepted to a PRTF out of state. Staff #47 revealed patients were kept inpatient as close to the time of admission to a residential facility; sometimes the patients would go home first, and then the family would transport them to the PRTF. Staff #47 revealed Pt #30’s family wanted a psychological evaluation for the Pt, but it was not offered at the facility anymore. Staff #47 made an appointment on their behalf for a psychological evaluation at Facility C with the day and time noted on the discharge sheet. Telephone Interview on 01/27/2025 at 1535 with Staff #30 revealed Staff #30 was the on-call admissions psychologist, who assisted admissions with determining if a patient met the criteria for IVC (involuntary commitment). Staff #30 covered all populations at the hospital (adult, adolescent, and child). Staff #30 was only responsible for IVC evaluations for patients and did not perform any other psychological testing or evaluations. Staff #30 revealed at one point, the facility had a psychologist who performed psychological, cognitive testing but was unsure if there was anyone currently. Interview on 01/28/2025 at 0910 with Staff #20 revealed the facility previously had a psychologist who performed evaluation and testing, but after they left in April 2024, they were not replaced due to the low volume of testing. Staff #20 had discussed this with Staff #3, who agreed that testing was infrequently needed. Staff #20 revealed Staff #30 preferred to do IVC evaluations but could also perform other assessments and evaluations if needed/requested. Staff #30 acknowledged the facility’s job descriptions had inadequate descriptions of job duties, and the facility was in the process of reviewing and updating these but had not updated Staff #30’s job description yet. NC00217667; NC00217755; NC00218498; NC00218743; NC00218789; NC00219198; NC00219332; NC00219796; NC00219847; NC00219896; NC00219970; NC00220111; NC00220706; NC00220914; NC00221039; NC00221233; NC00221241; NC00221299; NC00221389; NC00221413; NC00221425; NC00221895; NC00222154; NC00222168; NC00222408; NC00222848; NC00222906; NC00222927; NC00223079; NC00223169; NC00223368; NC00223421; NC00223815; NC00224145; NC00224147; NC00224494; NC00225763; NC00224785; NC00225195; NC00225261; NC00225541; NC00225678; NC00225819; NC00226240; NC00225942; NC00226152; NC00225873; NC00226254; NC00226287; NC00226540”

“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: 34065 Based on review of hospital policies , medical records, and interviews with staff, the facility failed to provide safe restraint use by failing to provide a signed restraint order within 24 hours in 1 of 5 patients with restraint orders (Patient #5). The findings include: Review of policy titled “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” with review date of 3/9/2022 revealed “Definitions: Chemical (Medication) Restraint: The administration of a medication for the purpose of controlling an acute episodic behavior, with the intent or actual effect to restrict the patient’s functioning or movement and/or to bring about sedation. Medical/Chemical restraint occurs when a patient is given a medication or combination of medications to control the patient’s acute episodic behavior or restrict the patient’s freedom of movement and/or which is not the standard treatment or dosage prescribed for the patient’s condition...if the specific purpose of administering that medication, at that dose, via that route, and at that time, is to impact acute episodic behavior, it qualifies as a chemical restraint....3.0 Physician Order, Consultation, and Evaluation 3.1 Restraint or seclusion shall be used in emergency situations only and requires an order from a physician. 3.1.5 The physician shall authenticate the order within 24 hours...” Review of the closed medical record for Patient #5 revealed a 63-year-old -male admitted as IVC (Involuntary commitment) on 01/25/2024 for schizoaffective disorder with Bipolar type (Mental disorder with feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania). Review of “Seclusion/Restraint Order” sheet dated 02/01/2024 at 1355 revealed “Medication/Chemical Restraint--Ativan (anti-anxiety medicine) 4 mg (Milligrams) IM (Intramuscular) x i (one time) agitation. Thorazine (treats mental health conditions. Helps with relaxation) 200 mg IM x i psychosis. Imminent Danger to Self. Imminent danger to Others....Arguing and very belligerent towards others, would not redirect, required IM injections to calm down s (without) a physical hold.” Review revealed “Telephone order by (NP #33 /RN #34).” Review of the MAR (Medication Administration Record) revealed Thorazine 200 mg IM and Ativan 4 mg IM was administered by LPN #35. Review revealed MD #32 signed order on 02/08/2024 at 1100, 7 days after the verbal order was obtained. Interview on 03/20/2024 at 1510 with RN #34, who has been an employee for 7 years, revealed no recollection of Patient #5. Interview revealed all restraint orders should be signed within 24 hours by the provider. Interview on 03/20/2024 at 1340 with NP #33 revealed “the restraint order should have been signed before 2/8/2024.” Interview revealed the order should have been signed within 24 hours. Interview on 03/21/2024 at 1000 with MD #32 revealed the restraint order should have been signed within 24 hours after the original order. Interview with the Medical Provider for Patient #5 revealed the hospital policy was not followed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 34065 Based on review of hospital policies, medical records, and interviews with staff, the facility failed to provide safe restraint use by failing to provide a face to face within 1 hour after a chemical intervention on 1 of 5 patients who were restrained. (Patient #5). The findings include: Review of hospital policy titled “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” with review date of 3/9/2022, revealed “Definitions: Chemical (Medication) Restraint: ....5.0 Face to Face Evaluation by the Physician, LIP (Licensed Independent Practitioner), or trained RN: Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized LIP [(PA--Physician Assistant, NP (Nurse Practitioner)], or trained RN. The evaluation will be documented in the medical record to include the following: 5.1 The date and time of the evaluation 5.2 An assessment of the patient’s immediate situation 5.3 An evaluation of the patient’s reaction to the intervention 5.4 An assessment of the patient’s medical and behavioral condition to include a complete review of systems assessment, behavioral assessment as a review and assessment of the patient’s history, drugs and medications, most recent lab work, etc. 5.5 An assessment of the need to continue or terminate the restraint. ...If the evaluation is conducted by a trained RN, he/she must consult with the attending physician or other LIP responsible for the patient’s care as soon as possible (within 30 minutes) after the evaluation. This consultation should include a discussion of the findings of the 1-hour evaluation, the need for other interventions or treatments, and the need continue or discontinue the use of restraint/seclusion....” Review of the closed medical record for Patient #5 revealed a 63 year-old-male admitted as IVC (Involuntary commitment) on 01/25/2024 for schizoaffective disorder with Bipolar type (Mental disorder with feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania). Review of “Seclusion/Restraint Order” sheet dated 02/01/2024 at 1355 revealed “Medication/Chemical Restraint--Ativan (anti-anxiety medicine) 4 mg (Milligrams) IM (Intramuscular) x i (one time) agitation. Thorazine (treats mental health conditions. Helps with relaxation) 200 mg IM x i psychosis. Imminent Danger to Self. Imminent danger to Others....Arguing and very belligerent towards others, would not redirect, required IM injections to calm down s (without) a physical hold.” Review revealed verbal “Telephone order by (NP #33/RN #34).” Review of the MAR (Medication Administration Record) revealed Thorazine 200 mg IM and Ativan 4 mg IM was administered by LPN #35. Review revealed no documentation of a face-to-face evaluation within an hour by the physician or NP. Interview on 03/21/2024 at 1000 with MD #32 revealed Patient #5 did not have a face-to-face evaluation within an hour after the IM injections on 02/01/2024. Interview revealed Patient #5 should have had an evaluation by a MD within the hour. Interview revealed the policy was not followed.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 38766 Based on review of the elopement report log, medical record, incident reports, corrective action plan, facility floor plan, daily inspection log, and staff interviews, the hospital staff failed to accurately collect and analyze data for safety actions implemented for seven (7) of seven doors after a patient elopement. Findings include: Review of the elopement log from 10/01/2023 through 03/19/2024 revealed Patient # 20 eloped from the facility on 01/03/2024 and on 03/10/2024. Open medical record review on 03/19/2024 revealed Patient #20 was a 15-year-old-male who presented to the hospital under involuntary commitment with suicidal ideations (SI) and aggression on 12/23/2023 and was admitted on 1C South - the adolescent boys’ unit. The patient endorsed SI with an attempt to hang himself with a bedsheet and an ongoing plan to cut his wrist. The patient had a history of seven (7) suicide attempts and numerous psychiatric admissions since the age of eleven (11). The patient diagnoses included Post Traumatic Stress Disorder (PTSD), Oppositional Defiant Disorder (ODD), and Attention Deficit Hyperactivity Disorder (ADHD). Review of the Standardized Intake Assessment on 12/23/2023 revealed that involuntary legal status was checked as the elopement risk factors and the initial nursing assessment on 12/23/2023 revealed no indications for elopement risk. Review of admission orders on 12/23/2023 revealed the patient’s level of observation was for every 15 minutes, and the Precautions/Interventions was unit restrictions (UR) until face-to-face evaluation with provider. The unit restrictions was discontinued after the physician assessment on 12/24/2023 at 1015. On 12/25/2023 at 1800 the patient was placed on elopement precautions after an incident where the patient kicked through the entrance door of the unit in pursuit of a staff member. A behavior management plan was initiated on 12/26/2023 at 1200 following the incident of agitation, aggression and kicking of the unit door by patient #20 identified coping skills to help de-escalate future situations, with plans for identifying coping skills, following the unit rules, and accepting direction from the staff. The plan included a 1:1 meeting at the end of each shift with staff to discuss behavior, progress that has been made, and feedback to the patient. Review of the Psychiatric Progress Note on 12/28/2023 revealed that the patient stated that he did not want to leave the hospital or run away and was just “frustrated”. The review revealed the elopement precautions were discontinued on 12/28/2023 at 1213 after the provider’s assessment. Review revealed on 01/03/2024 the patients on the unit were instructed to their rooms at approximately 1745 due to the unit being “out of control” and two staff were posted in the hallway. Patient #20 ran into another patient’s room. As staff approached the room, Patient #20 ran from the room towards the end of the hall, kicked the door open and eloped from the hospital. Review of the Patient Observation Sheet on 01/03/2023 revealed the patient was logged out to elopement at 1746 and logged in from elopement at 2136 (3hours and 50 minutes). Review revealed Patient #20 was located by named police department at the CVS pharmacy and was taken to an outside hospital for a medical screening and returned to the facility. A behavior management plan was initiated on 01/04/2024 at 0800 following the incident of elopement by patient #20. Patient #20 was then placed on elopement precautions and 1:1 (one-to-one observation) per doctor’s order but the orders were discontinued on 01/08/2024 based on physician clinical judgement. On 03/10/2024 at approximately 1400, Patient #20 kicked the exit door and eloped from the facility. RN #28 noted at 1400, Patient #20 “ran through hallway, pushing exit door and forced door to open (same door as in 01/03/2024 elopement). Two more patients [Patients #3 and #15] followed him. Supervisor notified.” At 1430 RN #28 noted that “legal guardian was called, giving information and voiced understanding. We will follow up later”. RN #4 update at 1935 stated: “patient returned to unit via police department. ...skin assessment completed. Patient has scratch on left arm...” A behavior management plan was initiated on 03/11/2024 at 0800 following the incident of elopement by patient #20 along with two other patients. Review of physician order revealed Patient #20 was placed on elopement precautions on 03/10/2024 at 2200. MD #3 progress note on 03/09/2023 at 1251 stated “...continues to wait on news from placements. Pt [patient] has ongoing high-risk behaviors and concerns for safety that require long-term referrals.” On 03/11/2024 at 1104 MD #3 noted “pt kicked open the door at the end of the hallway and eloped from the hospital. Pt returned sometime later. Pt has ongoing mood lability (rapid mood changes) and frequent behavioral issues. Pt is looking for placement at this time and is waiting on news for long-term care.” Review on 03/20/2024 of the incident report following the elopement of Patient #20 on 01/03/2024 indicated the time of the elopement/AWOL (absent without leave) was 1730. The comments indicated: “... down the hall, there were two members of staff. This patient was near his room when he ran into another patient’s room. The patient was seen running down the hall towards the exit door as staff intervened. The staff heard a loud bang, and the patient was out the door. Staff searched the grounds for this patient, but he was not found. Supervisor was notified, a code walker was called, RPD (police department) was called, and a report was taken, the provider was notified, and the AOC [guardian] was notified...” Addendum from Director #10 on 01/18/2024 stated: “patient was located approximately 1.5 hours later one mile down the road at a local CVS. Patient had injury on arm from cutting himself with scissors. Patient was transported by EMS [emergency medical services] to local ED (emergency department) to determine the need for any medical treatment. Patient was returned that evening with no medical treatment necessary.” Incident report on 03/10/2024 indicated the time of the elopement was 1400. The comments indicated: “named patient running with other two patients pushing the exit door at the end of the hallway and eloped from the facility.” Addendum from Director #13 on 03/12/2024 at 0844 stated: “patient returned to named facility by PD, no injuries noted upon assessment, no crimes committed during elopement. Elopement precautions are in place and patient has been placed on unit restriction, patient will remain in gown and socks per policy.” Review on 3/20/2024 of the facility’s corrective action plan regarding the 03/10/2024 incident that involved Patients #20, #3, and #15 revealed, Director #11 removed operational function of exterior door used in elopement (boarded up door) and fire safety protocol was established and training was provided for the inoperable door on 03/10/2023. The action plan revealed a contractor was obtained and presented to the campus for fencing upgrade design on 03/11/2023. Review on 03/20/2024 of the Children Hospital building floor plan revealed seven (7) exit doors located in different hallways. The review revealed that the exit doors were not identified on the plan. A review on 03/20/2024 of the Children’s Hospital Unit Exit Door Mag [magnet] Lock Daily Inspection revealed that the daily inspection was initiated on 01/29/2024. The daily inspection log failed to reveal any documentation on February 3, 4, 10, 11, 17, 18, 24, 25 of 2024 March 2, 3, 9, 10, 16, and 17 of 2024 (14 of 51 days). The review revealed magnets were “tightened” on January 31, 2024, February 5, 6, 15, and 22 of 2024, and March 5, and 7 of 2024. The review revealed no indication of which door and which magnet needed to be tightened. Interview on 3/20/2024 at 1330 with CEO - Chief Executive Officer, Directors # 10, 11, 12, and 13 revealed, that the exit doors had a magnetic lock at the top and bottom with a large piece of safety glass in the middle. Interview revealed Patient #20 “whaled on the door and the force against the door caused the door to bend and became compromised. Interview revealed the door was temporarily out of order and new doors were ordered. The plan also consisted of building a foyer outside of the exit doors to deter further elopements. The interview revealed that the plant operation was conducting daily environment of care rounding to ensure that the doors were not compromised. Interview on 03/25/2024 at 1225 with Tech #16 revealed the doors in the children’s building were previously labeled but the labels were removed during painting, cleaning, and repairs. The Technicians were expected to inspect the magnets on each door daily and repair or tighten the magnets as needed. The interview revealed the Maintenance Technicians were also expected to document which door needed to be tightened, but Tech #16 stated “we usually don’t because we communicate with each other”. The interview revealed that the maintenance staff only work Monday through Friday, and the Mental Health Technicians were expected to conduct the inspection of the doors on weekends, but Tech #16 did not know where they (the staff) documented their inspections. A request was made to hospital management about the weekend log for the daily inspection of the doors in the children’s hospital. The hospital management failed to provide a weekend inspection log.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 50318 Based on policy review, medical record review, incident report review, corrective action plan review, personnel file review, and staff interviews, the facility staff failed to develop an effective corrective action plan by not monitoring to ensure two staff members were present in the courtyard after 1 of 3 elopements at the facility involving the same patient (Patient #3). Findings included: Review on 03/20/2024 of the facility’s policy, “Elopements: Prevention and Response” effective 06/98, with facility review on 06/28/21, revealed, “Universal prevention of elopements require the following: two staff members must be present for all off-unit group activities. When outdoors, one staff member will position themselves closest to the fence line or wall, while the other staff member stands at the opposite end of the courtyard to ensure full line of sight. Redirect patients to stand away from unit doors, fence lines and walls.” Closed medical record review on 03/19/2024 revealed, Patient #3 was admitted to the facility on 02/09/2024 as an IVC (involuntary commitment) due to SI (suicidal ideations) and HI (homicidal ideations) and was housed on the adolescent boys’ unit. The patient was initially ordered elopement precautions (EP) due to IVC and being a new admit until MD #3 conducted initial psychiatric evaluation the following day. On 02/10/2024 at 1000, MD #3 conducted the initial psychiatric evaluation of the patient which revealed, the patient presented with SI/HI, was combative in the home and was running away frequently. The patient endorsed SI with no current plan but was self-harming per cutting with plastic on arms and has a history of suicide attempt by jumping off of a parking deck. At 1217, the patient had orders to discontinuation of EP. Review revealed, the master treatment plan addressed SI/HI with goals focused on coping skills and regulating emotions. The patient was noted to be calm/content and involved during group therapy/activities from 02/10/2024 to 02/13/2024 (4-days). However, on 02/14/2024, group notes revealed, the patient was continuously redirected and refused to complete the group activity. On 02/15/2024 at 1500, nurse’s note revealed patient #3 with another peer attacked and had an altercation with a peer who was disruptive during group, resulting in staff intervening and separating the patients. After the peer-to-peer incident, Patient #3 was anxious and pacing. MD #3 was notified, and the patient was administered Zyprexa (for mental/mood conditions) 20 milligrams orally and Benadryl 50milligrams orally, and the legal guardian was notified. A behavior management plan was initiated on 02/16/2024 at 0850 following the peer-to-peer incident with patient #3 identifying coping skills to help de-escalate future situations, with plans to have a 1:1 at the end of each shift with staff to discuss behavior and what progress has been made. On 02/16/2024, during morning and evening group therapy/activities, patient #3 was noted to be focused, involved, and calm. On 02/17/2024, per patient observation sheet, patient #3 was in the patio/yard area at approximately 1015 during fresh air time. At approximately 1030, patient #3 scaled the fence and jumped over to the other side. RN #6 noted at 1130, patient #3 “jumped the fence during outside time and eloped. Police have been called and are looking. Parents aware and are understanding. Will f/u [follow-up] with any updates”. RN #6 update at 1258 stated: “Police unable to locate; patient placed on missing person list. Parents aware and understanding”. RN #6 update at 1305 stated “[Case number]” with officer’s last name. MD #3 progress note at 1210 stated “pt [patient] eloped from the hospital this morning and has not returned to the hospital as of the time the doctor came around the unit to see patients. Pt was reported missing, and police and family were informed”. Review revealed, the patient had not returned to the facility within 48 hours and was noted to be “discharged” from the facility on 02/19/2024. Review on 03/17/2024 of the incident report for Patient #3 revealed, the incident time noted as 1030 for elopement/AWOL (absent without leave). Comments stated: “Patient climbed and jumped over the fence during fresh air time. Police were unable to find him. He was placed on missing person list. Parents are aware and understanding. [Case number]”. Review revealed, an addendum from Director #13 on 02/19/2024 stated: “To date, patient has not been found and no updates have been provided by family or police; will continue to follow up.” Review on 03/20/2024 of the facility’s corrective action plan regarding the 02/17/2024 incident that involved Patient #3 revealed, Director #11 examined the fence, and determined it was not compromised. However, a contractor was secured to fabricate a metal side rail to the fencing to decrease the ability to scale the fence. A review of the Elopement policy and procedure was conducted on 02/18/2024, and one staff member was identified as having been non-compliant with Elopement policy and procedure. The staff member went out on leave, unrelated to the incident. Review of staff positioning in the outdoor area was conducted and revealed that the staff member was not standing in the appropriate position for fence monitoring, which is covered in the elopement policy training and attestation in the New Hire Orientation. Medical record review was conducted and revealed that the patient observation rounds were compliant per policy; also, the patient was placed on elopement precautions at admission, but these were lifted based on physician clinical judgment and order. Review revealed, the corrective actions did not include monitoring of fresh air time to ensure two staff members were present in the courtyard with patients. Interview on 03/20/2024 at 1330 with CEO, Directors # 10, 11, 12, and 13 revealed, the fence was not compromised, was considered an “anti-climb fence” with a slanted section of fence at the top, and there was a “tiny gap” (less than 1/2 inch) between the fence and the building. A metal fabricator was constructing an additional stainless steel side panel to cover said gap between the fence and the building for an additional resource to prevent this from occurring again, with an estimate of 30 days of completion. Interview revealed, MHT #7 did not follow protocol for positioning, with only MHT #7 present outside at that time with a group of about 14 of 18 adolescents while the second staff member was at lunch. Request on 03/21/2024 of security camera review for when patient #2 scaled the fence revealed, the video was unavailable for review. Review on 03/26/2024 of MHT #7 personnel file revealed that MHT signed off on the elopement policy during new hire orientation on 01/07/2021, and a performance improvement plan was initiated on 02/28/2023 regarding every 15 minute checks not being conducted on patients, and the MHT met with the lead trainer on 03/06/2023 for re-education.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 40299 Based on policy review, contract agreement, medical record review and staff interview, the facility staff failed to identify, report and implement preventive measures after the prescribing provider was not notified of a critical lab value for 1 of 2 sampled patients with new orders for lithium (Patient # 4). The findings included: Review on 03/25/2024 of policy “OCCURRENCE REPORTING” reviewed dated 07/2023 revealed “The responsibility for completing a Healthcare Peer Review (HPR) report rests with any hospital staff member who witnesses, discovers, or has direct knowledge of an occurrence. Occurrence are defined as any happening not consistent with the routine care and/or operation of the facility which may place the facility at increased risk for liability.” Review on 03/25/2024 of policy “CRITICAL VALUES TEST RESULTS” reviewed 01/2020 revealed “It is the policy of (Hospital A) to notify the physician immediately of any critical value test results ...” Review on 03/21/2024 of the policy “LABORATORY SERVICES” reviewed 02/2020 revealed “It is the policy of (Hospital A) to provide laboratory services through contractual agreements. Specimens will be collected by (Company C) Phlebotomist or authorized (Hospital A) staff ... Results Laboratory results are processed and available per (Company C) and (Hospital B) policy. 1. All lab results are available in HCS, on the (Company C) Web Site, or by calling the (Hospital B) Laboratory. 2. Critical value results are called into the unit by the laboratory with a concurrent faxed copy. b. The RN receiving the critical value will notify the physician immediately ...” Review on 03/21/2024 of the “Outsourced Laboratory Testing Services Agreement” signed 07/02/2019 revealed “... This Laboratory Testing Services Agreement (the ‘Agreement’) is entered into as of the effective date of the 1st (first) day of July, 2019, by and between (Company C) ... and (Hospital A’s Corporate Name) ... EXHIBIT A - PERFORMANCE METRICS ... 6. Corrected and Amended Results, Critical Value, and State Reportables Notification ... B. Notification. Vender shall notify the applicable Affiliate by phone or Critical Values ...Notification of Critical Values will be in accordance with the standard ranges ... In addition to notifying Affiliate of Corrected and Amended Results, Critical Values and State Reportables, Affiliate (Company C) representative must provide to Affiliate Laboratory Director or other representative with a cause analysis and corrective action plan for all failures to communicate and document Corrected and Amended Results, Critical Values and State Reportables ...” Closed medical record review on 03/20/2024 revealed Patient #4 was a 15-year-old female admitted to the facility on 01/24/2024 at 1319 under IVC (involuntary commitment) for suicidal ideations. Review of the Medication Administration Record (MAR) revealed Patient #4 was started on Lithium ER (extended release) tablet 300 mg (milligrams) twice a day on 01/25/2024 at 2012. The patient was administered the Lithium ER twice a day on 01/26/2024, 01/27/2024, 01/28/2024, 01/29/2024, 01/30/2024, 01/31/2024 and one time in the morning on 02/01/2024. Provider Orders revealed an order on 01/30/2024 at 0600 for Lithium Serum with Start time of 01/30/2024 at 0600 and Stop time of 01/30/2024 at 0810. Review of the Lithium Serum result dated 02/02/2024 at 1157 revealed a result of 2.4 (reference range was 0.5-1.2). Review of the medical record did not reveal documentation the critical result was called to facility. Review of the medical record revealed Patient #4 was discharged home on 02/01/2024 at 1231. Interview on 03/21/2024 at 1345 with MD #3 revealed Patient #4 “had a negative outcome.” MD #3 spoke with multiple people including Patient #4’s Cardiologist and the Pharmacist #42 here prior to starting Lithium. Patient #4 was taking the medication enalapril and it will increase the blood levels of lithium which can lead to lithium toxicity. Monitoring the patient for signs of lithium toxicity and monitoring the lithium level with lab draws was the plan and agreeance to start the lithium. MD #3 ordered the Lithium level however Patient #4 discharged prior to MD #3 getting the result back. MD #3 received a telephone call from Patient #4’s family letting him know Patient #4 was in the emergency department (ED) with a critical lithium level. MD #3 shared the information from the telephone call with Pharmacist #42 and requested she contact Company C to get the lithium result at discharge. Interview revealed a pending lithium level is not a reason to keep a patient in the hospital when they are ready for discharge. MD #3 revealed lithium levels are usually back the next morning after it is drawn. Interview revealed had he (MD #3) received a call with the critical lab value of the lithium he would have stopped the Lithium and sent Patient #4 to the ED instead of discharging her. Interview on 03/22/2024 at 1240 with Pharmacist #42 revealed MD #3 wanted to order Lithium for Patient #4 who was already taking Enalapril for her heart valve. Lithium is contraindicated as the ace inhibitor would increase the lithium level. It was discussed and felt if would be safe as long as got a lithium level prior to discharge. Pharmacist #42 revealed she heard Patient #4 had discharged before the Lithium level was back from the lab. Interview revealed MD #3 notified Pharmacist #42 Patient #4 was in the ED with an elevated lithium level. Pharmacist #42 called Company C three times before she was able to get the lithium result. Patient #4 discharged on 02/01/2024 and Pharmacist #42 contacted Company C on 02/02/2024. The lithium level was drawn on 01/30/2024 and the result should have been returned prior to Patient #4 discharging. Interview revealed it is ultimately up to the Provider to get the results of labs that are ordered. There is no policy that speaks to this practice and who is responsible for retrieving lab results. Interview revealed Pharmacist #42 did not enter an incident report nor did she report it to anyone to enter in the reporting system. Interview revealed Pharmacist #42 “cannot enter incident reports.””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 50111 Based on policy review, observation, and staff interview the facility staff failed to monitor nourishment storage equipment to ensure safety and quality for 6 of 6 nourishment refrigerators observed on the adult campus. The findings include: Review on 03/26/2024 of the hospital policy “TEMPERATURE LOGS- Policy No.: 024” last revised 01/09/2023, states “PROCEDURE: To record temperatures of all refrigerator/freezer/cooler equipment as well as dish machines on a daily basis ... ACTION: ... 2. Logs are to be completed daily as assigned. 3. Logs are to be kept on file for one year in the Food Service Directors office. 4. If a piece of equipment is not in use, either out of service or not needed for that day’s duties, “Not In Use” should be noted in the comments section of the log.” Observation on 03/26/2024 at 1020 of nourishment refrigerator (#3), located on unit 1 South, failed to reveal any nourishment refrigerator temperature logs on the unit. Request for temperature logs failed to reveal any temperature logs located on the unit during observation. Review on 03/26/2024 at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#3), located on unit 1 South, failed to reveal log completion for the months of January 2024 (31 of 31 days) and February 2024 (29 of 29 days). Review revealed temperatures for the month of March 2024 were completed for one day, on 03/26/2024. Review failed to reveal temperature documentation in March 2024 for 25 of 26 days. Observation on 03/26/2024 at 1025 of nourishment refrigerator (#4), located on unit 1 West, revealed nourishment refrigerator temperature logs for October 2023 through December 2023. Observation failed to reveal refrigerator temperature logs for January 2024 through March 2024. Review on 03/26/2024 at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#4), located on unit 1 West, failed to reveal documented temperatures for the month of January 2024 on the following dates: 01/01/2024, 01/03/2024, 01/06/2024 through 01/09/2024, 01/14/2024 through 01/16/2024, 01/20/2024, 01/21/2024, 01/29/2024, and 01/31/2024 (13 of 31 days). Review failed to reveal documented temperatures for the month of February 2024 on the following dates: 02/02/2024 through 02/04/2024, 02/09/2024 through 02/11/2024, 02/16/2024 through 02/19/2024, and 02/23/2024 through 02/26/2024 (14 of 29 days). Further review failed to reveal a log was completed for the month of March 2024 (25 of 25 days). Observation on 03/21/2024 at 1232 of nourishment refrigerator (#1), located on unit 1 East, revealed storage of patient snacks. Observation failed to reveal a refrigerator temperature log for the month of March 2024. Review on 03/26/2024 at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#1), located on unit 1 East, revealed temperatures for the month of January 2024 were completed for all dates. Review failed to reveal documented temperatures for the month of February 2024 on the following dates: 02/03/2024, 02/09/2024, 02/16/2024 through 02/18/2024, 02/20/2024, 2/21/2024, and 02/23/2024 through 02/27/2024 (12 of 29 days). Review failed to reveal a temperature log for the month of March 2024 (25 of 25 days). Interview during observation on 03/22/2024 at 1245 with RN#23 revealed there was no March 2024 nourishment refrigerator temperature log on the unit. When asked about the March 2024 log she stated, “It is not here.” RN#23 revealed the log was normally completed by night shift staff. Observation on 03/26/2024 at 1038 of nourishment refrigerator (#6), shared by units 2 East and 2 West, failed to reveal any nourishment refrigerator temperature logs on the unit. Nurse Manager #17 was unable to locate refrigerator temperature logs. Review on 03/26/2024 at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#6), shared by units 2 East and 2 West, failed to reveal a log was completed for the month of January 2024 (31 of 31 days). Review failed to reveal documented temperatures for the month of February 2024 on the following dates: 02/02/2024 through 02/06/2024, 02/09/2024 through 02/11/2024, 02/13/2024 through 02/19/2024, and 02/23/2024 through 02/25/2024 (18 of 29 days). Review failed to reveal documented temperatures for the month of March 2024 on the following dates: 03/01/2024, 03/08/2024, 03/15/2024, and 03/21/2024 through 03/25/2024 (8 of 25 days). Observation on 03/26/2024 at 1030 of nourishment refrigerator (#5), shared by units 2 North A and 2 North B, revealed a nourishment refrigerator temperature log for March 2024. Review of the March 2024 log failed to reveal temperature documented on 03/20/2024 and 03/25/2024. Observation failed to reveal refrigerator temperature logs for January 2024 and February 2024. Review on 03/26/2024 at at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#5), shared by units 2 North A and 2 North B, failed to reveal documented temperatures for the month of January 2024 on 01/09/2024, 01/11/2024, and 01/23/2024 (3 of 31 days). Review failed to reveal temperature documentation on 02/14/2024 for the month of February 2024 (1 of 29 days). Review failed to reveal documented temperatures for the month of March 2024 on 03/20/2024 and 03/25/2024 (2 of 25 days). Observation on 03/26/2024 at 0955 of nourishment refrigerator (#2), shared by units 1 North A and 1 North B, revealed storage patient snacks. Observation of the March 2024 temperature log failed to reveal temperatures documented for several dates. Observation failed to reveal refrigerator temperature logs for January 2024 or February 2024. Review on 03/26/2024 at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#2), shared by units 1 North A and 1 North B, failed to reveal documented temperatures for the month of January 2024 on 01/09/2024, 01/11/2024, and 01/23/2024 (3 of 31 days). Review revealed documented temperatures for the month of February 2024 for all dates. Review failed to reveal documented temperatures for the month of March 2024 on 03/23/2024, 03/24/2024, and 03/25/2024 (3 of 25 days). Interview on 03/26/2024 at 1140 with Director #9 revealed nourishment refrigerator temperature logs were to be completed daily by night shift staff. Director #9 acknowledged there was missing documentation and stated that there were “gaps in the logs” and “some units may not have logs.””

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 50111 Based on observation, policy review, observation, medical record review, patient advocate complaint worksheet review and staff interviews the facility failed to coordinate an orderly discharge by failing to provide a medication prescription at discharge for 1 of 15 discharged patients (Patient #24) and failing to provide an aftercare appointment for 1 of 15 discharged patients (Patient #5). The findings included: Review of policy titled “Discharge Planning” with revision date of 10/22 revealed “Discharge planning begins the day of admission for all patients served by (named facility). Discharge planning is discussed daily and at each Treatment Team Meeting for a patient. 2. The Therapist/Case Manager discusses discharge options with the patient and legal guardian...3. Reviews preliminary discharge plan and discharge criteria with patient and guardian....8. Patients are expected to attend an aftercare appointment within 7 days from their discharge date, typically with a therapist.” 1. Observation on 03/26/2024 at 1000, on unit 1 North B, revealed a patient was in the process of receiving the patient discharge paperwork and review of the instructions. Review of the discharge paperwork with Nurse Manager #18 and RN#20 revealed the medication prescription was electronically prescribed according to documentation on the “DISCHARGE MEDICATION SUMMARY FOR PATIENT.” The form contained the name, address, and telephone number for the pharmacy under the “THESE DISCHARGE PRESCRIPTIONS e-PRESCRIBED TO:” section of the form. Closed medical record review for Patient #24 (Pt#24) revealed an 18 year old male patient that presented to the facility on 08/31/2023 with Involuntary Commitment documents (a legal process through which an individual is deemed by a qualified person to have symptoms of severe mental disorder and is detained in a psychiatric facility involuntarily) for depression and suicidal ideation with plans to harm himself. Review revealed Pt #24 was discharged home on 09/06/2023. Review of the “DISCHARGE MEDICATION SUMMARY FOR PATIENT” revealed a list of discharge medications. Review of the discharge medication list included LamoTRIgine 200 milligrams (mg) once a day, FluvoxaMINE 150 mg at bedtime, Brexpiprazole 2 mg at bedtime, and Gabapentin 100 mg three times a day. Review failed to reveal documentation that disharge medications were prescribed for Pt#24. Review of the Patient Relations Worksheet on 03/21/2024, completed by a Patient Care Advocate (PCA#24) on 09/06/2023 (no time documented), revealed a complaint was received by phone. The description stated Pt#24’s (family member) requested the medication prescription be called in to the pharmacy to avoid a delay in receiving the medications. The worksheet stated the complaint was resolved on 09/06/2023 with an action of “PA [Patient Advocate] provided request to treatment team.” Interview during 1 North B observation on 03/26/2024 at 1000, with a Nurse Manager (Nurse Manager #18) and a Registered Nurse (RN#20), revealed the process for reviewing discharge paperwork and verification of medication prescriptions. RN#20 revealed the pharmacy name, location and phone number must be documented under the “THESE DISCHARGE PRESCRIPTIONS e-PRESCRIBED TO:” section of the form to verify that the prescription was electronically sent by the physician. Interview revealed if a paper prescription was provided, a copy of the paper prescription would be placed in the patient’s chart. Interview revealed prescriptions were sometimes called into the pharmacy. Interview with RN#20 on 03/22/2024 at 1145 revealed RN#20 did not recall Pt#24. RN#20 reviewed the discharge paperwork in the medical record and revealed the prescription medications were not electronically prescribed. RN#20 confirmed there was no paper prescription located in Pt#24’s medical record. RN#20 stated MD#21, Pt#24’s doctor, preferred to call in medication prescriptions to the pharmacy. Interview revealed if the medication prescription was not electronically prescribed and a paper prescription was not provided, RN#20 would normally follow up with the provider to ensure that the medication prescription had been called in to the pharmacy prior to discharge. RN#20 did not recall following up the MD#21 about the medication prescription for Pt#24. Interview with a Patient Care Advocate (PCA#24) on 03/22/2024 at 1040 revealed PCA#24 contacted the treatment team after receiving a phone call complaint that Pt#24’s medication prescription was not called in to the pharmacy. Interview revealed that PCA#24 would typically receive confirmation from someone in the treatment team that the request had been completed. PCA#24 did not recall if the treatment team had followed up with notification that the medication prescription was called in to the pharmacy. Interview with a Licensed Clinical Social Worker (Therapist #25) on 03/22/2024 at 1100 revealed Therapist #25 recalled PCA#24 emailed a request for Pt#24’s prescription to be sent to the pharmacy. Interview revealed Therapist #25 notified MD#21. MD#21 was unavailable for interview. 34065 2. Review of the closed medical record for Patient #5 revealed a 63 year old male admitted as IVC (Involuntary commitment) on 01/25/2024 for schizoaffective disorder with Bipolar type (Mental disorder with feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania). Review of Patient #5’s After Care/Discharge Plan dated 02/08/24 at 3:30 PM revealed Therapist #1 documented in “Appointment Date/Time” slot: “Unable to schedule apt (appointment) LG (Legal Guardian) did (sic) not provide an apt...” Review revealed the facility failed to arrange an appointment for discharge follow up for Patient #5. Interview on 03/20/2024 at 1430 with Therapist #1 revealed the aftercare appointment was not made for Patient #5. Interview on 03/20/2024 at 1530 with ACDS #8 revealed the after care appointment was not made for Patient #5. Interview revealed the discharge packet contained the information for the aftercare facility. Interview revealed the discharge disposition was appropriate but aftercare appointment was not arranged. Interview revealed the policy was not followed for arranging an aftercare appointment.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 26622 Based on review of facility policy, medical records and staff interviews, the facility staff failed to ensure a Master Treatment Plan was completed and/or updated in 4 of 11 medical records reviewed (Patient #11, Patient #2, Patient #5 and Patient #25); and legal guardian signature on Treatment plan on 1 of 11 medical records reviewed (Patient #5). The findings include: A. Review on 03/22/2024 of the policy titled “Interdisciplinary Patient-Centered Care Planning” revised 05/2023, revealed “..Procedure...4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan. ...The treatment team will complete the MTP (Master Treatment Plan)... ...b. Completion of an individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheet will include the problem, specific patient behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention. ... Interdisciplinary Treatment Plan Update 1. ...A treatment plan revision can be completed any time the treatment team decides to alter the proposed strategies based upon the patient’s needs. Reviews of the treatment plan are documented on the appropriate treatment plan forms in the medical record. The following would be cause for conducting a review of the plan and developing a revision: ... A major change occurs in the patient’s clinical condition, such as the need for the use of restraint or seclusion. ... The patient fails to reach treatment goals despite reasonable clinical care. ... The treatment team determines the patient’s current treatment plan would more appropriately be delivered on an individual basis rather than group interventions.” 1. Closed medical record review on 03/20/2024 for Patient #11 revealed a 15-year-old male admitted to the facility on 09/23/2023 with a diagnosis of psychosis and disruptive mood dysregulation disorder. Review of the medical record revealed no documentation of a Master Treatment Plan completed from 09/23/2023 through 02/29/2024. Patient #11 was discharged to a Residential Treatment Facility on 02/29/2024. Interview on 03/21/2024 at 1635 with ADCS #8 revealed that a Master Treatment Plan should have been completed for Patient #11. ADCS #8 reviewed Patient #11’s medical record and was unable to locate documentation of a Master Treatment Plan. 50318 2. Closed medical record review on 03/20/2024 revealed, patient #2 was admitted to the facility on 02/06/2024, voluntary status, due to SI (suicidal ideations) and was housed on C1 South - adolescent boys’ unit. On 02/06/2024 at 2200, nurse’s note revealed that MHT (mental health technician) #28 was doing observation checks, and when MHT got to patient #2’s room, patient #2 started hitting the MHT and attempted to put the MHT in a chokehold. MHT did not fight back and attempted to get out of the situation. Code one (psychiatric emergency) was called and staff helped remove MHT from the situation. MHT #28 sustained a “bleeding nose and swelling in left eye”; patient #2 did not sustain any injuries. Legal guardian was informed, as well as the provider on call, and patient was placed on aggression precautions. MD initial psychiatric evaluation was conducted on 02/07/2024 at 1100 with MD #3. The evaluation revealed, the 16-year-old patient presented with SI, walked into the road in effort to be hit by a car, with history of at least three prior suicide attempts, including one in January 2024 with an overdose of anti-depressants. The evaluation also revealed, “prior to being seen by psychiatrist, pt [patient] was assaultive towards staff that entered room to do 15 minute checks and gave MHT [#28] a bloody nose”. Clinical assessment conducted by therapist #29 on 02/07/2024 revealed, a history of arrests in 2019-2020, 2023 for battery & assault, and attempted murder. Therapist #29, along with patient #2, identified a short-term goal of “staying calm and work on aggression” with a long-term goal of stop using illicit substances. The master treatment plan and interdisciplinary master treatment plan was initiated on 02/07/2024 and addressed SI and substance use with goals focused on coping skills. MD #3 psychiatric progress note on 02/08/2024 at 1137 revealed, “pt [patient] presents severely aggressive behaviors including assaulting a staff member upon admission and severe mood instability. Pt shows poor insight but states he was doing better”. A behavior management plan was initiated on 02/09/2024 at 0900 following the patient-to-staff altercation on 02/06/2024, which noted patient #2 displayed little remorse nor provided a response for his actions; patient identified coping skills to help de-escalate future situations, with plans to have a 1:1 at the end of each shift with staff to discuss behavior and what progress has been made. Behavior plan also stated the expected behavior was for patient #2 to be in better control of impulse behaviors, and refrain from any display of aggressive or assaultive behaviors towards staff or peers; if patient’s behavior becomes disruptive, patient #2 will program in an area away from peer designated by the charge nurse or house supervisor. MD #3 psychiatric progress note on 02/09/2024 at 1125 revealed, “pt [patient] has been severely aggressive towards peers and staff and assaulted a peer this morning per hitting him. Pt has been arguing and instigating with peers, threatening peers and staff, and has ongoing assaultive behaviors. Pt is a danger towards others and has severe mood instability”. On 02/09/2024 at 1215 a chemical restraint was ordered for patient #2, as patient #2 walked on the countertop at the nurse’s station and across the printer to the other side of the nurse’s station; 1:1 verbal interaction was attempted prior to restraint but patient #2 was not re-directable. Patient #2 was administered Thorazine (for mental/mood conditions) 50 milligrams (mg) injection and Benadryl 50mg injection, and legal guardian was notified. Patient #2 had a master treatment plan problem sheet update for “restraint/seclusion/hold” following this incident, which noted “aggressive acting-out behavior requiring the use of a chemical restraint”; patient #2 was noted to be climbing over the nurse’s station and had a verbal altercation with another patient. MD #3 psychiatric progress note on 02/10/2024 at 1230 revealed, “Pt [patient] has been severely aggressive still and was in another altercation with a peer this morning. Per report pt was not the initiator of altercation but was yelling, arguing, and peer ran up on him. Pt presents severe anxiety and aggressive behaviors. Pt shows no improvement and is a danger towards others”. Therapist group note on 02/11/2024 at 1200, revealed that patient #2 was unfocused, needed additional learning, and was “fighting peer”. An update to the behavior management plan on 02/11/2024 [no time listed] revealed, patient #2 “was involved in several physical altercations with a peer due to patients continuous antagonizing of the individual”. On 02/11/2024 at 1450 a chemical restraint was ordered for patient #2, as patient #2 was involved in a physical altercation with a peer; 1:1 verbal interaction and reduced stimuli was attempted prior to restraint but patient #2 was noted to be “an imminent danger to others”. Patient #2 was administered Thorazine (for mental/mood conditions) 50mg injection and Benadryl 50mg injection at 1500, and legal guardian was notified. Patient #2 had a second master treatment plan problem sheet update for “restraint/seclusion/hold” following this incident, which noted “aggressive acting-out behavior requiring the use of a PRN [as needed] medication”. MD #3 psychiatric progress note on 02/12/2024 at 1111 revealed, “Pt [patient] has severe ongoing aggression and was in multiple altercations over the weekend. Pt shows little insight into mood or behaviors and has severe aggressive behaviors. Pt presents severe agitation”. MD #3 psychiatric progress note on 02/13/2024 at 1041 revealed, “Pt [patient] is expecting to discharge today and is safe to do so. Pt is not an acute danger towards self but has ongoing issues with behavior and conflict with peers. Greater than 30 minutes was spent planning and organizing this patient’s discharge”. Patient #2 was discharged home on 02/13/2024 at 1200 with legal guardian. Review failed to reveal the treatment plan was updated and failed to clearly indicate that 1:1 discussions occurred at the end of each shift. Incident report created on 02/06/2024 for patient #2, with incident time noted as 2100 for “Aggression Patient towards staff”. The comments revealed, MHT #28 was doing observation checks and when MHT got to patient’s room, patient started hitting MHT in the face and attempted to put MHT in a chokehold. MHT did not fight back and attempted to leave situation. Code one was called and staffed helped remove MHT from the situation. MHT sustained a bleeding nose and swelling in left eye. Patient did not sustain any injuries. Patient guardian was called and informed of this occurrence. Provider on call notified and patient placed on aggression. Incident report created on 02/09/2024 for patient #2, with incident time noted as 1135 for “Aggression Patient towards patient”. The comments revealed, patient in verbal altercation with another patient, belligerent attempting to fight but was held off from being in contact with the other patient. Patient separated and placed in a comfort room”. Incident report created on 02/09/2024 for patient #2, with incident time noted as 1215 for “patient out of control”. The comments revealed, “Pt [patient] out of control and aggressive towards staff and peers. Pt jumped on top of the nurse’s station and walked across the printer to the other side. Pt was not directable. Pt administered 100mg Thorazine IM [injection] and 50mg Benadryl per doctors order”. Incident report created on 02/10/2024 for patient #2, with incident time noted as 1020 for “Aggression patient towards patient”. The comments revealed, “patient was attacked by another patient following a verbal altercation”. Incident report created on 02/11/2024 for patient #2, with incident time noted as 1450 for “Physical confrontation with other patients”. The comments revealed, “Patient involved in physical altercation with peer. Patients separated for safety and de-escalation. Patient assessed for injury. Patient received PRN [as needed] medication per doctors order. Guardian notified”. Interview on 03/21/2024 at 1027 with ADCS (Associate Director of Clinical Services) #8 revealed, the ADCS did not recall patient #2, but reviewed patient #2’s chart and noted that the master treatment plan should have been updated to include aggression. The master treatment plan and interdisciplinary master treatment plan was initiated on 02/07/2024 and addressed SI and substance use with goals focused on coping skills; record review revealed that these plans were not updated to include aggression. ADCS revealed, the therapist should have based their goals off the patient’s history of chronic aggressive behavior. ADCS revealed, a behavior management plan was initiated on 02/09/2024 at 0900 following the patient-to-staff altercation on 02/06/2024, and should get updated with an action plan if continued aggression is noted. Record review revealed an update to the behavior management plan on 02/11/2024 [no time listed], which stated: patient #2 “was involved in several physical altercations with a peer due to patients continuous antagonizing of the individual”. Record review failed to provide clear indication of an updated action plan. Interview on 03/22/2024 at 1140 with therapist #2 revealed, the therapist recalled patient #2 but had limited interactions with this patient. Therapist revealed, the patient’s “behavior seemed worse than a previous visit [in January 2024] and always wanted to fight”, and previously, the staff could redirect the patient’s behavior. Therapist revealed, the patient was removed from group therapy on 02/09/2024, and the patient jumped over the nurse’s station. Telephone interview on 03/22/2024 at 1218 with RN #5 revealed, RN works PRN, typically on the adolescent girl’s unit, but recalled patient #2. RN revealed, patient #2 did not want to be separated after an argument with another patient on 02/09/2024; patient #2 was moved to C1 West B and did not want to stay there, and the patient jumped over the counter, and walked across the printer to the other side of the nurse’s station. RN revealed, patient #2 “was adamant” to be on C1 South instead. RN revealed, the staff attempted to “call him down”, and patient #2 “may have hit or slapped the glasses off a nurse” at that time. RN performed the 15 minute checks, following patient #2’s chemical restraint, and patient #2 went into another day room by himself and took a nap. RN revealed, patient #2 caused disruptions with groups/therapy and “was a problem the whole time, picking with a particular patient”. RN revealed, patient #2 was “very aggressive and adamant of what he was going to do and what he wasn’t going to do” during the patient’s hospitalization. 34065 3. Review of the closed medical record for Patient #5 revealed a 63 year old male admitted as IVC (Involuntary commitment) on 01/25/2024 for schizoaffective disorder with Bipolar type (Mental disorder with feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania). Review revealed the Master Treatment Plan was created on 01/26/2024, one day after admission. Review revealed no further documentation on the Master Treatment Plan. Patient #5 was discharged on 02/09/2024 at 1345, 14 days after admission. Interview on 03/20/2024 at 1430 with Therapist #1 revealed the MTP (Master Treatment Plan) should be reviewed every 7 days. Interview revealed “unsure why it was not done.” Interview revealed an entry for February 1, 2024 and February 8, 2024 was missing. 4. Review of the closed medical record for Patient #25 revealed a 24 year old female admitted on 01/14/2024 under IVC for paranoid thoughts, sleep difficulty and medication noncompliant. Review of the MTP revealed an initial date of 01/15/2024. Review revealed no further dates of review were documented. Patient #25 was discharged on 01/23/2024, 9 days after admission. Interview on 03/20/2024 at 1430 with Therapist #1 revealed the MTP should be reviewed every 7 days. Interview revealed “unsure why it was not done.” Interview revealed an entry for 01/22/2024 was missing. B. Review of the policy titled “Interdisciplinary Patient-Centered Care Planning” with revision date of 05/2023, revealed “...5. The patient/family and/or guardian is to sign the treatment plan to indicate their agreement with and participation in development of the plan. A designated staff member is responsible for discussing the treatment plan with the patient and family/representative/guardian if they are not present at the treatment team meeting....” Review of the closed medical record for Patient #5 revealed a 63 year old male admitted under IVC on 01/25/2024 with schizoaffective disorder with Bipolar type. Review revealed Patient #5 had a legal guardian. Review of the Master Treatment Plan revealed the guardian’s signature was not documented. Review revealed the facility policy was not followed. Interview on 03/22/2023 at 1535 with Therapist #1 revealed the legal guardian should have been notified of the MTP. The interview revealed a guardian signature or phone review from the guardian should have been present on the MTP. NC00214633; NC00214587; NC00214617; NC00214015; NC00214473; NC00212832; NC00211897; NC00214669; NC00213517; NC00213988; NC00204978; NC00207535; NC00203154; NC00206218; NC00207224”