Raleigh Oaks Behavioral Health

“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: 16369 Based on facility policy review, medical record review and staff interview, the facility staff failed to complete a face-to-face assessment within one hour after a violent physical restraint and seclusion intervention for 2 of 3 patient restraint records reviewed (Patients #7 and #26). The findings include: Review of facility policy “Seclusion and Restraint” revised 2/2026 revealed, “... Restraint or seclusion shall only be utilized in a psychiatric emergency, where a patient’s behavior presents imminent danger to self or others, as an intervention of last resort, and after less restrictive measures have been attempted without success. ... One-hour Face-to-face Assessment: A psychiatric provider or registered nurse must perform a face-to-face assessment of the patient’s physical and psychological status within one hour of the initiation of restraint or seclusion. A registered nurse who performs such assessments will be trained as a Qualified RN and have demonstrated competence in the assessment and management of violent behavior. ...” 1. Open medical record review on 03/25/2026 for Patient #7 revealed a 21-year-old who was admitted under IVC (involuntary commitment) on 03/14/2026 for bipolar disorder (a mental health condition characterized by significant mood swings, including manic and depressive episodes) and polysubstance abuse. On 03/15/2026 at 0908, an order for an emergency restraint was placed for a manual hold. Review revelaed the patient had punched another resident in the mouth and slapped another resident. The patient continued to threaten other residents and was not responsive to less restrictive measures. The patient was placed in a hold at 0908. Review of the record revealed a a face-to-face evaluation was documented at 1050 (1 hour and 42 minutes after initiation of the restraint). Record review failed to reveal documentation of a face-to-face evaluation within an hour by a Physician or qualified trained RN. Interview on 03/26/2026 at 1735 with Nursing Leader #1 revealed the face-to-face evaluation for Patient #7 was delayed. Interview revealed the face-to-face evaluation was not completed within one hour and should have been completed sooner. Interview revealed the restraint policy was not followed. 50318 2. Closed medical record review on 03/25/2026 for Patient #26 revealed a 22-year-old who was admitted under IVC (involuntary commitment) on 02/26/2026 at 1227 for psychosis (a disconnection from reality, including hallucinations, delusions, and disorganized thinking) with polysubstance abuse and increased aggression and anger. On 02/26/2026 at 1540, an order for seclusion was placed with a comment, “Patient attempting to scale nurses station - threatening to injure staff and self. Presenting with paranoid, psychotic thinking.” Seclusion started at 1540 and ended at 1702 (1 hour and 22 minutes total). A manual hold was initiated at 1648 and ended at 1701 (13 minutes total). Review of the patient orders failed to reveal an additional order for a manual hold. The narrative description of event requiring restraint or seclusion revealed, “Patient presenting with paranoid psychotic thought process. Attempting to scale nurses station while threatening to harm staff and self. Attempted to deescalate, bringing in different staff member and physician. Placed in seclusion and offered medications PO (orally) - declined and was given IM (intramuscular) meds as ordered.” Face-to-Face Evaluation was conducted on 02/26/2026 at 1730 (one hour and 50 minutes after the seclusion was initiated). The patient’s reaction to the intervention was listed as “resistant and agitated.” Record review failed to reveal documentation of a face-to-face evaluation within an hour by a Physician or qualified trained RN. Interview on 03/26/2026 at 1855 with Nursing Leader #1 revealed the Nursing Leader had performed the face-to-face evaluation for Patient #26. Interview revealed the face-to-face evaluation was not completed within one hour and should have been completed sooner. Interview revealed the restraint policy was not followed.”

“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: 53711 Based on facility policy, observation, and staff interviews, the facility failed to follow hospital policy ensuring patients’ home medications were returned at discharge for 21 of 21 observed bags of medications in a locked cabinet on Unit 900. (Patients #36, #31, #42, #41, #38, #28, #29, #43, #24, #33, #32, #37, #45, #39, #44, #40, #35, #30, #34, #25, #27) The finding include: Review of the hospital policy titled “Storage and Management of Patient Home Medication” last revised 10/2015 revealed “ ...PURPOSE: To ensure the safe, secure, and compliant handling, storage, and disposition of patients’ home medications brought into the psychiatric hospital upon admission ... RETURN OR DISPOSAL AT DISCHARGE: ... At discharge, home medications will be: Returned to the patient or authorized caregiver with signature acknowledgement or ... Disposed of according to pharmacy and environmental safety policy if return is declined or prohibited ... Documentation of return or disposal is required ... If medications are not returned at discharge, the patient will be contacted immediately upon discovery in 2 different methods (phone, email, written mail) 3 times over 30 days. If contact is not made with the patient and medications cannot be returned, they will be disposed of per disposal guidelines/policy ...COMPLIANCE AND MONITORING: Nursing leadership and pharmacy will monitor compliance of this policy through audits and incident reviews ... “ Observation on 03/24/2026 at 1330 on the 900 unit revealed twenty-one open bags stored in a locked medication-room cabinet, each with a medication log stapled to the bag and labeled with the patient’s name. All bags contained home medications belonging to patients who had already been discharged. 1. Review of patient #36 revealed the patient was discharged on 02/23/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 2. Review of patient #31 revealed the patient was discharged on 11/09/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 3. Review of patient #42 revealed the patient was discharged on 11/17/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 4. Review of patient #41 revealed the patient was discharged on 11/18/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 5. Review of patient #38 revealed the patient was discharged on 11/19/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 6. Review of patient #28 revealed the patient was discharged on 11/25/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 7. Review of patient #29 revealed the patient was discharged on 11/25/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 8. Review of patient #43 revealed the patient was discharged on 11/26/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 9. Review of patient #24 revealed the patient was discharged on 12/01/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 10. Review of patient #33 revealed the patient was discharged on 12/05/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 11. Review of patient #32 revealed the patient was discharged on 12/10/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 12. Review of patient #37 revealed the patient was discharged on 12/10/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 13. Review of patient #45 revealed the patient was discharged on 12/16/2025. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 14. Review of patient #39 revealed the patient was discharged on 01/13/2026. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 15. Review of patient #44 revealed the patient was discharged on 01/21/2026. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 16. Review of patient #40 revealed the patient was discharged on 01/28/2026. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 17. Review of patient #35 revealed the patient was discharged on 02/17/2026. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 18. Review of patient #30 revealed the patient was discharged on 02/18/2026. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 19. Review of patient #34 revealed the patient was discharged on 02/24/2026. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 20. Review of patient #25 revealed the patient was discharged on 02/27/2026. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. 21. Review of patient #27 revealed the patient was discharged but the facility was unable to verify discharge date. Observation revealed the patients’ home medication bag was still in the facility on 03/24/2026. Interview conducted on 03/26/2026 at 1400 with RN # 1 revealed home medications should have been returned to these patients at the time of discharge. Interview conducted on 03/25/2026 at 0930 with pharmacist #3 revealed that nursing staff is responsible for ensuring home medications are given to patients at discharge. Also, the bags are to be sealed once they are logged in at admission and are not to be opened by anyone except the pharmacist until given back to the patient at discharge. Interview conducted on 03/26/2026 at 1850 with Leadership #9 revealed the medications should have been sealed in a bag at time of admission and returned to patients at discharge. Interview revealed the nursing staff failed to follow the hospital’s policy for returning home medications to patients at the time of discharge.”

“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: 16369 Based on facility policy review, medical records review, and staff interviews, the facility staff failed to ensure elopement precautions were included in the Master Treatment Plan for 7 of 9 elopement precaution patients reviewed (Patients #9, #18, #7, #8, #26, #1 and #10). The findings include: Review of facility policy, “Treatment Plan Acute Inpatient” revised 3/16/2026 revealed, “... The interdisciplinary treatment planning process is the foundation of thorough comprehensive and effective treatment. ...Each patient admitted to the psychiatric unit shall have an individualized treatment plan which is based on interdisciplinary clinical assessments. ... The treatment planning process is continuous, beginning at the time of admission and continuing through discharge. ... Short term objectives should also be reviewed and added to, if appropriate or indicated. ...” Review of the “Elopement Precautions for Acute” revised 2/2/2026 revealed, “... Policy: The risk for elopement is assessed for all patients during the admission process and throughout hospitalization. Definitions: Elopement: A situation in which a patient leaves a secured or supervised area without authorization and when doing so poses a safety risk to the patient or others. ... 9. Treatment Team: a. Individualizes the patient’s plan of care by incorporating Elopement risk problem statements and goals to address restrictions as needed and delineating the elopement prevention interventions in the patient’s treatment plan necessary to maintain safety and prevent elopement. ...” 1. Open medical record review on 03/25/2026 of Patient #9 revealed a 56 year-old-male that was admitted on 03/20/2026 with a diagnosis of bipolar disorder (a mental health condition characterized by significant mood swings, including manic and depressive episodes) and depression. Review of a nursing note dated 03/22/2026 at 1110 revealed, “Pt (patient) was meeting with a SW (social worker) in the small conference room in the corner outside the entrance to the patient rooms. The SW and the patient were standing outside of the room when he started walking fast/briskly towards the courtyard door and she yelled for help. She stated he was trying to elope. Patient did grab the door several times and then looked around but did not attempt to leave through any other unit doors. Pt was encouraged by staff to return to his room and after several attempts he voluntarily walked back on the unit. No other behavioral issues.” Review of a Nurse Practitioner order dated 03/22/2026 at 1300 revealed an order for Elopement Precautions due to the patient trying to leave the unit. Review of the Behavioral Health Observation Sheets for 03/23/2026, 03/224/2026 and 03/25/2026 showed the patient was on Elopement Precautions. Review of the Master Treatment Plan (MTP) initiated on 03/20/2026 revelaed no problem identification, goals or interventions included on the MTP. Review revealed the Master Treatment Plan was signed on 03/22/2026 at 1444 by nurse that documented the elopement risk on 03/22/2026 at 1110. Interview on 03/26/2026 at 1450 with the Director #2 revealed Elopement Precautions should have been added to the Master Treatment Plan when the patient showed signs of attempting to leave. Interview revealed the facility staff failed to follow the hospital policy. 2. Closed medical record review on 03/25/2026 of Patient #18 revealed an 18 year-old-male that was admitted on 03/03/2026 with a diagnosis of major depressive disorder. Review of an Intake assessment dated 03/03/2026 at 1559 recorded an “Elopement Risk” as “Patient is cognitively impaired with poor decision-making” with Level of Care Recommendations left blank. Review of the Treatment Recommendations listed the patient was to be on every 15 minute observations. Review of a “High Risk Notification From” used to communicate patient information during hand off from the admissions area to an inpatient unit revealed :elopement risk: poor cognition”. Review of admission orders revealed no order for elopement precautions. Review of the Patient Observation Sheet revealed the patient was on elopement precautions initiated on 03/03/2026 at 1639. Review of a nursing note dated 03/06/2026 at 1725 revealed “Elopement Risk, Narrative Note: The patient kicked the unit door and exited, activating a code green. The patient then kicked the hallway door and proceeded all the way to the admission hallway. Behavioral Health Assistants brought him back, and the patient, waiting in the hallway, expressed a desire to go to the 900 unit. The supervisor was informed and will arrange for a bed in the 900 unit.” Review of the Master Treatment Plan (MTP) initiated on 03/04/2026 at 1003 with an update on 03/11/2026 revelaed no problem identification, goals or interventions included on the MTP. Interview on 03/26/2026 at 1450 with the Director #2 revealed Elopement Precautions should have been added to the Master Treatment Plan when the patient showed signs of attempting to leave. Interview revealed the facility staff failed to follow the hospital policy. 3. Open medical record review on 03/25/2026 for Patient #7 revealed a 21-year-old who was admitted under IVC (involuntary commitment) on 03/14/2026 for bipolar disorder and polysubstance abuse. Review of a “High Risk Notification Form” dated 03/14/2026 at 2254 recorded “Elopement Risk: IVC, packing, risky agitation” and listed an observation level of every 15 minutes. Review of a “Patient Observation Sheet” revealed the patient was placed on elopement precautions on 03/14/2026 at 2251. Review of a physician’s telephone order dated 03/14/2026 at 2223 for Elopement Precautions. Review of the patient’s Master Treatment Plan dated as completed on 03/16/2026 revealed no problem identification, goals or interventions included on the MTP. Review revealed a “risk of elopement” was added as a problem with interventions added to the MTP on 03/25/2026 (11 days after the patient was placed on elopement precautions). Interview on 03/26/2026 at 1450 with the Director #2 revealed Elopement Precautions should have been added to the Master Treatment Plan when the patient was identified as an elopement risk and placed on precautions. Interview revealed the facility staff failed to follow the hospital policy. 4. Open medical record review of Patient #8 revealed an 18 year-old-male that was admitted under involuntary commitment (IVC) on 03/09/2026 with auditory hallucinations and delusions. Review of a “High Risk Notification Form” dated 03/09/2026 at 1144 recorded “Elopement Risk: yes, threatened to escape in admissions” and listed an observation level of every 15 minutes. Review of a physician’s telephone order dated 03/09/2026 at 1117 for Elopement Precautions. Review of a “Patient Observation Sheet” revealed elopement precautions were added to the observation sheet on 03/09/2026 at 1129. Review of the patient’s Master Treatment Plan dated as completed on 03/12/2026 with an update on 03/16/2026 revealed no problem identification, goals or interventions included on the MTP. Review revealed a “risk of elopement” was added as a problem with interventions added to the MTP on 03/17/2026 (8 days after the patient was placed on elopement precautions). Interview on 03/26/2026 at 1450 with the Director #2 revealed Elopement Precautions should have been added to the Master Treatment Plan when the patient was identified as an elopement risk and placed on precautions. Interview revealed the facility staff failed to follow the hospital policy. 50318 5. Closed medical record review on 03/25/2026 for Patient #26 revealed a 22-year-old who was admitted under IVC (involuntary commitment) on 02/26/2026 at 1227 for psychosis (a disconnection from reality, including hallucinations, delusions, and disorganized thinking) with polysubstance abuse and increased aggression and anger. Review of the patient’s orders revealed elopement and homicide/assault (danger to others) precautions were ordered at 1237. The precautions were also noted on the electronic patient observation sheet for every 15 minute checks. The patient’s Master Treatment Plan (MTP) was initiated on 02/26/2026 with interventions and goals added on 02/27/2026 and 02/28/2026. MTP Problem #1 was listed as “Psychiatric - Paranoid and/or Delusional Thoughts or Behaviors r/t (related to) paranoid (believes that the nurses out of [sic] harm and other patients).” MTP Problem #2 was listed as “Restraint and Seclusion - Danger to Others: Aggression, Anger, Homicidal Risk r/t Paranoid and Delusional Thoughts (Attempting to scale nurses station partition and assault staff).” Review of the MTP failed to reveal elopement precautions were listed as a psychiatric problem or interventions associated with reducing elopement risk. Interview on 03/26/2026 at 1450 with the Director #2 revealed Elopement Precautions should have been added to the Master Treatment Plan when the patient was identified as an elopement risk and placed on precautions. Interview revealed the facility staff failed to follow the hospital policy. 47421 6. Closed medical record review on 03/24/2026 for Patient #1 revealed a 32-year-old male voluntarily admitted on 02/23/2026 for suicidal ideation (thoughts of suicide) and homicidal ideation (thoughts of homicide). Record review revealed the patient was an elopement risk (leaving a healthcare facility without staff awareness) and was placed on elopement precautions on 02/23/2026 at 1659. The elopement precautions were also noted on the patient observation sheet for every 15-minute checks. Review of the master treatment plan failed to reveal the risk for elopement as a documented psychiatric problem. Interview on 03/26/2026 at 1450 with the Director #2 revealed Elopement Precautions should have been added to the Master Treatment Plan when the patient was identified as an elopement risk and placed on precautions. Interview revealed the facility staff failed to follow the hospital policy. 7. Closed medical record review on 03/26/2026 for Patient #10 revealed a 38-year-old male voluntarily admitted on 03/16/2026 for hallucinations. Record review revealed the patient was an elopement risk (leaving a healthcare facility without staff awareness) and was placed on elopement precautions. The elopement precautions were also noted on the patient observation sheet for every 15-minute checks. Review of the master treatment plan revealed the risk for elopement was not initially documented as a psychiatric problem but later identified on 03/25/2026. Interview on 03/26/2026 at 1450 with the Director #2 revealed Elopement Precautions should have been added to the Master Treatment Plan when the patient was identified as an elopement risk and placed on precautions. Interview revealed the facility staff failed to follow the hospital policy.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 17281 Based on record review, acute record review, interview, and policy review, the hospital failed to ensure effective communication between nursing and provider staff for receipt of telephone orders for chemical restraints for one of three (Patient (P) 6) patients reviewed for chemical restraint and the hospital failed to provide the necessary supervision to prevent a patient elopement for one of three (Patient (P) 5) reviewed for elopement risk in a total sample of 10 patients. The hospitals failure to have effective staff communication and failure to prevent a patient elopement placed the health and safety of patients at risk for serious injury, serious harm, serious impairment, or death and resulted in Immediate Jeopardy. Findings include: A conference was held with Interim Chief Executive Officer, Chief Nursing Officer (CNO), and Clinical Director (CD) on 01/20/26 at 3:50 PM to inform them of an Immediate Jeopardy (IJ) under § 482.13 Condition of participation: Patient’s rights, specifically §482.13(c)(2) care in a safe setting for failure of the medical record to include documentation of the sequence of events prior to and after the administration of chemical restraints, CPR (cardiopulmonary resuscitation) initiation and timeline from unresponsiveness and initiation of CPR, EMS (emergency medical services) arrival, and hand off and transfer to the acute care hospital. The hospital failed to ensure the patient’s medical record included communication between nursing staff and provider staff regarding medication orders for sedation. The IJ template was provided to the hospital on 01/20/26 at 3:50 PM. The hospital presented a Plan of Removal on 01/21/26 at 1:56 PM. The Plan of Removal was not accepted by the State Agency/CMS at the time of the exit conference on 01/22/26 at 11:05 AM. The IJ remained in place. A conference was held with Interim Chief Executive Officer, CNO, Corporate Vice-President of Quality and Patient Safety (VPQ), and Executive Assistant (EA) on 01/21/26 at 4:50 PM to inform them of an IJ under § 482.13 Condition of participation: Patient’s rights, specifically §482.13(c)(2) care in a safe setting for failure to prevent a patient who was a danger to self and others from obtaining the Unit 700 exit door key from the certified nursing assistant (CNA) and failure of the unit staff to make any attempt to stop the patient from eloping from the hospital that resulted in the patient being fatally struck by a vehicle on 08/30/25 shortly after eloping. The hospital presented a Plan of Removal on 01/22/26 at 9:15 AM. The Plan of Removal was not accepted by the State Agency/CMS at the time of the exit conference on 01/22/26 at 11:05 AM. The IJ remained in place. Cross reference A0144- Patient Rights: Care In Safe Setting- A patient has the right to receive care in a safe setting. Cross reference A1084 - Patient Rights: Restraint Seclusion- A face-to-face medical and behavioral evaluation is conducted within one hour if restraint or seclusion is used to manage violent or self-destructive behavior. Cross reference A0186- Patient Rights: Restraint Seclusion- less restrictive interventions attempted before use of restraint or seclusion. Cross reference A0188- Patient Rights: Restraint Seclusion- The patient’s response to the interventions used for restraint or seclusion, including the rationale for continued use of the intervention. Cross reference A0493- Pharmacist Personnel- The pharmaceutical service must have an adequate number of personnel to ensure quality pharmaceutical services, including emergency services.”

“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: 17281 Based on record review, acute record review, interview, and policy review, the hospital failed to ensure the medical record included accurate documentation that represented the patient’s status, a chronological timeline during a crisis situation, and evidence of the response to treatment provided for one of three (Patient (P) 6) reviewed for chemical restraints. The hospital’s failure to ensure the medical record contained information on actual events the patient experienced and outcomes of treatment in the hospital had the potential to affect all patients receiving care in the hospital. Findings include: Cross Reference A1655- Recording progress notes. Specifically, the progress notes recorded by staff responsible for the patient’s treatment and care must give a chronological picture of the patient especially when a crisis situation exits.”

“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: 28613 Based on record review, acute record review, interview, facility video review, and policy review, the hospital failed to ensure effective communication between nursing and provider staff for receipt of telephone orders for chemical restraints for one of three (Patient (P) 6) patients reviewed for chemical restraint and the hospital failed to provide the necessary supervision to prevent a patient elopement for one of three (Patient (P) 5) reviewed for elopement risk in a total sample of 10 patients. The hospitals failure to have effective staff communication and failure to prevent a patient elopement placed the health and safety of patients at risk for serious injury, serious harm, serious impairment, or death and resulted in Immediate Jeopardy. Findings include: 1. Review of P5’s Face Sheet dated 08/29/25 located in the Electronic Medical Record (EMR) under the “Table of Contents” tab revealed P5 was involuntarily admitted to the hospital on 08/29/25 at 11:34 AM due to increased aggressive behavior and destruction of property. Review of the “Intake Assessment” dated 08/29/25, located in P5’s EMR under the “Intake Assessment” tab, revealed P5 had not taken medications for the past week and described P5’s behavior as “impulsive.” Review of the “Initial Psychiatric Evaluation” dated 08/30/25 located in P5’s EMR under the “Table of Contents” tab, listed the admitting diagnosis as schizoaffective disorder with medication noncompliance. The patient denied any suicidal or homicidal ideation and was placed on routine 15-minute checks. Review of the “End of Shift Notes” dated 08/30/25 at 1:42 AM, located in P5’s EMR under the “Daily Nursing Progress Note” tab revealed, “Pt [Patient] has difficulty falling asleep and staying asleep. Pt paces the hall at baseline.” Review of the “End of Shift Notes” dated 08/30/25 at 9:03 PM, located in P5’s EMR under the “Daily Nursing Progress Note” tab revealed, “Patient has not slept for periods of time, has been up all day participating in groups, on the hallway with peers. Talked with father during phone time, yelling and cussing at him. Inhaler refused, states meds keep [P5] up all night.” Review of the “Narrative Note” dated 08/30/25 at 8:00 PM located in P5’s EMR under the “Table of Contents” revealed, “ ...”Pt snatched unit keys from [CNA 1] and ran to the back exit door off unit, used it to open the door and ran out at 8:00 PM. Writer followed after pt; however, pt ran into the woods and writer was not able to catch up with [P5]. . . 911 called . . . police officers came and continued the search.” The note was e-signed by RN 8 at 08/31/25 at 10:41 AM. An “Addendum” to the “Initial Psychiatric Evaluation” dated 08/30/25 found in P5’s EMR under the “Table of Contents” tab revealed, “At approximately 8:50 PM, writer received call from the nurse on 700 unit who reported that this patient [P5] had eloped. Police are present and are searching for the patient. [P5’s] parents have been notified. During an interview on 01/19/26 at 1:45 PM, Registered Nurse (RN) 2 stated that P5 was non-compliant with taking Zyprexa while hospitalized. During an interview on 01/19/26 at 2:15 PM, the Interim Chief Executive Officer stated that some documentation in P5’s record would be late entries because the medical record was “locked down” after the elopement. Observation of the facility video dated 08/30/25 that showed P5 eloping from the hospital was observed with the Chief Nursing Officer (CNO) on 01/20/26 at 1:00 PM in a provided office. The facility video started recording on 08/30/25 at 7:55 PM and showed P5 and two other patients walking back and forth in the hallway on Unit 700. CNA 1 was observed walking into the nurses’ station and returning in a few seconds. At 7:57 (and 47 seconds) PM, P5 grabbed the key from CNA 1’s wrist and started running down the hall toward the locked exit door that goes to the outside. CNA 1 was observed running after P5 but suddenly slowed down and started to walk. P5 exited the door at 7:57 (57 seconds) PM. CNA 1 was approximately six feet away from P5 when he/she went through the door and exited the hospital. During a telephone interview on 01/20/26 at 2:00 PM, CNA 1 was asked about the elopement of P5. CNA 1 recalled walking onto the unit on 08/30/25 and the patients were more agitated than usual. The patients were asking to go outside, which was not on the schedule at that time. CNA 1 took the patients to the dayroom and then went into the nurses’ station to get the remote for the television. CNA 1 thought the patients would quiet down if they could watch something entertaining. CNA 1 stated when he/she came out of the nurses’ station door, P5 “snatched my keys off my wrist and started running down the hall.” When asked why he/she slowed down when going after P5, CNA 1 stated “RN 1 cautioned me to slow down, yelling ‘CPI, CPI’ (Crisis Intervention Institute that provides verbal and physical techniques to manage challenging, high stress behaviors.) When asked why RN 1 would yell that, CNA 1 stated, RN 1 “Wanted to slow me down because of fear that I would not use proper CPI techniques and would be disciplined.” CNA 1 stated regret for slowing down and listening to RN 1 because, “I think I could have prevented the elopement by blocking the door.” Review of CNA 1’s personnel record on 01/20/26 identified completion of CPI training on 02/25/25 with renewal due by 02/28/26. During a telephone interview on 01/20/26 at 2:30 PM, RN 1 was asked about P5’s elopement from the hospital on 08/30/25. RN 1 acknowledged seeing CNA 1 running after P5 and saying something about keys. RN 1 yelled to CNA 1, “Don’t do that, stop it.” When asked why RN 1 yelled that, RN 1 stated that in Africa when someone stole something from you, you did not chase them. RN 1 also recalled saying “CPI, CPI” several times for fear that CNA 1, who was much bigger than P5, would hurt P5 and CNA 1 would be disciplined for not using an approved CPI hold. RN 1 also remembered yelling, “No legs, no legs” because of fear that CNA 1 would tackle P5. When RN 1 was asked if administration provided individual feedback regarding his/her actions and role in the incident on 08/30/25, RN 1 stated, “No individual feedback had been given.” RN 1 stated he/she received training about patient elopements after the incident on 08/30/25 and that staff are not to look for eloped patients in the woods or try to subdue them outside. 17281 2. Review of P6’s “Face Sheet” located in the EMR under the “Table of Contents” tab revealed P6 was admitted to the hospital on 10/05/25 with diagnoses that included schizoaffective disorder and type 1 diabetes mellitus. Review of the “Initial Psychiatric Evaluation Acute” dated 10/05/25 located in the EMR under the “Table of Contents” tab revealed, “ ...The patient is a 37 year old [male/female] admitted via involuntary commitment due to marked behavioral changes and bizarre conduct observed both at home and in the facility ...The patient’s psychiatric history is significant for schizophrenia, schizoaffective disorder (bipolar type) ...Hospitalization will provide the structure, monitoring, and medication management needed to stabilize his condition and ensure the safety of both the patient and those around him ....” Review of P6’s “Medication Administration Record (MAR)” dated 10/06/25 at 12:46 AM located in the EMR under the “Order” tab revealed Thorazine (medication used to treat severe mental health conditions)100 milligrams (mg) (intramuscular) IM, “now” was administered for psychosis, Ativan (medication used to treat anxiety) 2mg IM “now” was administered for anxiety, and Benadryl (sedative) 50mg IM “now” were administered for an emergency medical situation. Review of the nurse “Narrative Note” dated 10/06/25 at 12:56 AM, located in the EMR under the “Table of Contents” tab revealed, “Pt [patient] requesting for [his/her] personal property and [his/her] clothes. Pt is educated that the clothes are locked up in the reception area until the morning, in which [he/she] remarks, “Go get it”. Writer requested for donation clothes to mental health tech [technician] and was given a sweater and pants. Because the clothes were too small pt became irritable, agitated, after demanding [his/her] clothes. Pt stated, “You are not a true friend”, verbal redirection was ineffective. Pt punched the medication window closed fist, kicking the unit double doors and kicking the back exit to outside door. Provider [name] NP was notified and pt [patient] received one time orders for Thorazine 100mg IM Ativan 2mg IM, and Benadryl 50 mg. No manual hold was necessary to administer the medication. Debriefing was concluded reviewing unit clothing policy, elopement policy, and stress and coping.” Review of the nurse “Narrative Note” dated 10/06/25 at 3:36 AM, located in the EMR under the “Table of Contents” tab revealed, “ ...Pt is irritable after roommate waking him up. Pt is hitting all the door of the unit- Pt threw water at staff.” Review of the “MAR” dated 10/06/25 at 3:36 AM located in the EMR under the “Order” tab revealed, Haldol (medication to treat mental illness) 10 mg IM “now”, Ativan 2mg IM “now”, and Benadryl 50mg IM “now” were given for an emergency medical situation. Review of the “MAR” dated 10/06/25 at 5:04 PM, located in the EMR under the “Order” tab revealed onetime Stat (give at once) telephone orders for Ativan 2mg oral, Benadryl 200mg oral, and Thorazine 200mg oral were administered for agitation. Review of the “MAR” dated 10/06/25 at 6:44 PM, located in the EMR under the “Orders” tab revealed onetime Stat telephone orders for Thorazine 200mg IM, Versed 5mg (a powerful medication used in medical settings for sedation) IM, and Benadryl 200mg IM were administered to P6 for agitation. Review of P6’s EMR on 01/19/26 from 3:00 PM through 4:30 PM with Lead Case Manager (LCM) 1 and Registered Nurse (RN) 2 failed to reveal the EMR included any documentation of progress notes or assessments by Registered Nurse (RN) 3 who was assigned to provide care to P6 on 10/06/25 for the 7 AM -7 PM shift. The EMR failed to include any documentation of the sequence of events that led to P6 receiving chemical restraints on 10/06/25 at 5:04 PM and 6:44 PM, the communication provided to Nurse Practitioner (NP) 1 on 10/06/25 at 5:04 PM and 6:44 PM to warrant orders for chemical restraints including the medications P6 received earlier on 10/06/25. The EMR failed to reveal documentation of the sequence of events that led to P6 becoming pulseless and without respirations, initiation of Cardiopulmonary Resuscitation (CPR), EMS arrival and P6 being transferred to the acute care hospital. Review of P6’s EMR failed to include any documentation an assessment was conducted or vital signs obtained after medications were administered on 10/06/25 at 3:05 AM, 10/06/25 at 5:04 PM, and 10/06/25 at 6:44 PM. Review of the “Critical Care Note” located in P6’s acute care hospital EMR revealed, “ ... Patient is coming from [hospital name]. Patient had arrived at facility [psychiatric hospital] on the night of 10/05/25. Per EMS [Emergency Medical Services] report, staff at facility stated that his blood glucose levels were running high, gave him an extra dose of insulin. They observed that patient got agitated on the phone, became combative with the facility staff. In an attempt to calm patient down, staff gave pt 5mg Versed IM, 200mg Thorazine IM, and 200mg of Benadryl IM and called for EMS due to pt [patient] being combative. [name local police] also responded and when they arrived at the facility, they advised that pt was in cardiac arrest. CPR started by facility staff along with O2 [oxygen] by BVM [bag value mask]. EMS found patient lying on floor with adequate CPR and ventilations. Initial rhythm on monitor was PEA [pulseless electrical activity]. They attempted to pace several times with no capture. After several rounds of CPR and meds, patient converted to V-Tach [rapid heartbeat above 100 beats per minute] and was shocked once. After shock, patient regained pulses with irregular bradycardia [slow heartrate]. Pacing attempted again with capture and patient maintained pulses. Was transferred to the ED at [acute care hospital name] on 10/06/25 ...admitted to the Medical Intensive Care Unit (MICU) with cardiac failure, circulatory failure, respiratory failure, renal failure, and Central Nervous System (CNS) failure ....” Review of the “Discharge Summary Note” located in P6’s acute care hospital EMR dated 10/09/25 revealed, ...”Hospital Course [patient name], a 37-year-old patient, had a history of DM [diabetes mellitus]1, schizoaffective disorder, bipolar disorder, and alcohol/substance abuse. On 10/6/2025, [he/she] suffered a prolonged cardiac arrest after sedative-induced respiratory failure, requiring >20 min CPR and resuscitation with epinephrine [medication used in cardiac arrest]. Post-arrest, [he/she] developed severe respiratory and lactic acidosis, which resolved, and required vasopressors for shock. Neurologically, [he/she] remained unresponsive with absent brainstem reflexes and imaging confirmed diffuse cerebral edema [brain swelling] and hypoxic-ischemic injury [brain injury when blood flow and oxygen is reduced]. Formal brain death testing, including nuclear flow study, confirmed brain death on 10/9/2025 at 9:40 AM ....” During an interview on 01/20/26 at 11:42 AM, RPh1 stated the hospital pharmacy is open Monday through Friday from 8:00 AM to 3:00 PM and on weekends from 8:00 AM to 2:00 PM. An on-call pharmacy provides services after hours. If there are any prescriptions that need to be verified after hours they are verify off-site. RPh1 stated medications for administration to patients are stored in the Omni Cell (medication storage) on each unit. If there are verbal, telephone, or Stat medication orders after hours that are not in the Omni Cell, the nurse can call the remote pharmacy. Stat orders after hours require the nurse to call the remote pharmacy. RPh1 stated if during pharmacy hours there is a concern with prescribed medications including Stat medications; he/she speaks directly to the provider not the nurse. RPh1 stated administering Versed, Benadryl, and Thorazine together would cause sedation and the onetime medications ordered and administered on 10/06/25 at 5:04 PM and 6:44 PM were reviewed. RPh1 stated if he/she was aware of the onetime only Stat medication orders on 10/06/25 at 5:04 PM and 6:44 PM, the provider would have been contacted to inform him/her of the concern the amount of medication was “too much and too soon” because the orders were only one hour and 40 minutes apart. RPh1 stated administering the medications is a risk for Central Nervous System (CNS) depression. During an interview on 01/21/26 at 11:55 AM, NP1 stated he/she was the on-call provider on duty on 10/06/25. NP1 stated he/she received a call from RN3 on 10/06/25 at around 5:00 PM because P6 hit another patient. NP1 stated a Stat telephone order was given for oral medications (Benadryl, Ativan, Thorazine). NP1 stated he/she received a second call from RN3 around one hour later. RN3 was in a panic acting very anxious and yelling was heard in the background. RN3 said P6 was on the floor and won’t take any po (oral) medication and refused his/her insulin. RN3 stated P6 needed IM medications because he/she was refusing oral medications. NP1 stated orders were given for IM medication and RN3 was told if he/she can’t give the IM medications to call the police. NP1 stated he/she was down the street and decided to come to the hospital and when he/she arrived on the unit three behavioral health technicians were with the patient outside the 800 hallway and where trying to obtain the patient’s blood pressure and pulse. RN4 was with P6 and said there was a faint pulse. NP1 stated he/she assessed P6, could not find a pulse and told staff to get the AED and call a Code Blue (medical emergency response team). Resuscitative equipment was brought to the area and when the AED was placed, “No shock advised” sounded. CPR was started with RN4 and continued for about 10 rounds alternating with other staff until EMS arrived and took over. When asked if he/she was aware the patient received the ordered Ativan 2mg, Benadryl 200mg, and Thorazine 200mg oral at 5:04 AM, NP1 said “No” RN3 told me P6 had not taken any po medications. NP1 stated if aware P6 took the po medications ordered at 5:04 AM, RN3 would have been asked what else had been done to de-escalate the situation. NP1 stated he/she would questioned what de-escalation techniques were tried to give the po meds longer to work because it had only been a little over an hour since administered. NP1 stated, “If that didn’t work I would have ordered different IM medications.” During an interview on 01/21/26 at 1:00 PM, RN3 stated he/she was the nurse assigned on 10/06/25 for the 7:00 AM to 7:00 PM shift on the 700 unit. RN3 stated a behavior technician (didn’t remember who) reported P6 hit another patient and NP1 was called and ordered po Thorazine, Benadryl, and Ativan to be given Stat. RN3 stated NP1 told him/her if P6 did not take the po medication to call him/her back. RN3 stated P6 came off the unit to the common area to make a phone call. The conversation lasted about 5 minutes and after the call, P6 started yelling and became very agitated. RN3 stated NP1 was called and told P6 was agitated and aggressive. RN3 stated he/she did not tell NP1 that P6 took the po medications ordered at 5:04 PM because everything “went so fast”. RN3 stated NP1 gave orders for Versed, Thorazine, and Benadryl IM. RN3 stated when he/she went to give the IM medications with RN6, P6 was on his/her left side being held by Behavior Health Technician (BHT)1 and BHT2. P6 looked at me but did not say anything. RN3 stated he/she was in the medication room and did not know exactly when CPR started. RN3 stated he/she was not involved with any de-escalation techniques prior to administering the IM medications. RN3 stated an assessment of P6 was not conducted after the po meds were given at 5:04 PM and did not conduct any monitoring of P6 after the IM medications were given at 6:40 PM. RN3 stated he/she did not come back to P6 until after CPR was started. During an interview on 01/22/26 at 10:00 AM, the Medical Director stated he/she started employment at the hospital in December 2025. The Medical Director reported hearing of the event with P6 on 10/06/25 but did not have specific information to share. When told of the events on 10/06/25 involving P6 receiving Ativan 2mg oral, Benadryl 200mg oral, and Thorazine 200mg oral on 10/06/25 at 5:04 PM and Thorazine 200mg IM, Versed 5mg IM, and Benadryl 200mg IM on 10/06/25 at 6:44 PM, the Medical Director stated he/she had never heard of Versed being adopted as a standard of care in this type of hospital setting but rather in a setting such as an acute care hospital emergency room for sedation during a painful procedure where continuous monitoring can be provided. The Medical Director stated he/she had never heard or seen “that dosing” referring to the doses of Versed, Benadryl, and Thorazine IM ordered on 10/06/25. The Medical Director stated the doses of Thorazine and Benadryl were high and considering the medication received at 5:04 PM and Versed, the combination would cause sedation and risk for CNS depression. The Medical Director stated Versed should be removed from the hospital formulary. Review of the hospital policy titled, “Seclusion and Physical Restraint revised 12/05/25 revealed, “ ...Documentation: Patient Medical Record - The following information shall be recorded in the patient’s medical record for each episode of restraint and/or seclusion: A physician order as specified in section C-4 above, b. Completion of the designated form for use in restraint and seclusion, which includes at least the following: The type of intervention used, the name of the physician authorizing the intervention, the date and time the intervention began and terminated, the name of the staff initiating the intervention, with signature, date, time and credential of the staff, the name, title and credential of all staff present at the beginning of the intervention and witnesses, the role of each staff member involved in the intervention, to include roles during the intervention. to include positions and observer roles, the continuous observation of the patient must be documented (q.15) throughout the intervention, the times of additional interventions and assessments conducted during the restraint or seclusion, the least restrictive measures attempted prior to the intervention and the response to said interventions, the patient’s response to the restraint or seclusion, if the patient refuses to participate in any part of the required assessment, the refusal must be documented. along with continued attempts to complete the assessment. Progress Notes: A progress note must be written corresponding with the event by the RN ....” Review of the hospital policy titled, “Code Blue” effective date 12/18/25 revealed, “ ... All events surrounding the emergency will be documented in the patient’s medical record ....””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 17281 Based on record review, interview, and policy review, the hospital failed to ensure a face to face evaluation was conducted for one of three (Patient (P6 ) reviewed for the use of chemical restraint out of a total sample of 10 patients. This failure had the potential to affect any patient in the hospital that required the use of a chemical restraint. Findings include: Review of P6’s “Face Sheet” located in the EMR under the “Table of Contents” tab revealed P6 was admitted to the hospital on 10/05/25 with diagnoses that included schizoaffective disorder and type 1 diabetes mellitus. Review of the “Initial Psychiatric Evaluation Acute” dated 10/05/25 located in the EMR under the “Table of Contents” tab revealed, “ ...The patient is a 37.year.old [male/female] admitted via involuntary commitment due to marked behavioral changes and bizarre conduct observed both at home and in the facility ...The patient’s psychiatric history is significant for schizophrenia, schizoaffective disorder (bipolar type) ...Hospitalization will provide the structure, monitoring, and medication management needed to stabilize his condition and ensure the safety of both the patient and those around him ....” Review of the “Medication Administration Record (MAR)” dated 10/06/25 at 12:46 AM located in the EMR under the “Order” tab revealed Thorazine (medication used to treat severe mental health conditions)100 milligrams (mg) IM (intramuscular), “now” was administered for psychosis, Ativan (medication used to treat anxiety) 2mg IM “now” for anxiety, and Benadryl (sedative) 50mg IM “now” for an emergency medical situation. Review of the nurse “Narrative Note” dated 10/06/25 at 12:56 AM, located in the EMR under the “Table of Contents” tab revealed, “Pt [patient] requesting for his personal property and his clothes. Pt is educated that the clothes are locked up in the reception area until the morning, in which he remarks, “Go get it.” Writer requested for donation clothes to mental health technician and was given a sweater and pants. Because the clothes were too small pt became irritable, agitated, after demanding his clothes ...verbal redirection was ineffective. Pt punched the medication window closed fist, kicking the unit double doors and kicking the back exit to outside door. Provider [name] was notified and pt received one time orders for Thorazine 100mg IM Ativan 2mg IM, and Benadryl 50 mg. No manual hold was necessary to administer the medication. Debriefing was concluded reviewing unit clothing policy, elopement policy, and stress and coping.” Review of the nurse “Narrative Note” dated 10/06/25 at 3:36 AM, located in the EMR under the “Table of Contents” tab revealed, “ ...Pt is irritable after roommate waking him up. Pt is hitting all the door of the unit- Pt threw water at staff.” Review of the “MAR” dated 10/06/25 at 3:36 AM located in the EMR under the “Order” tab revealed, Haldol [medication to treat mental illness] 10 mg IM “now”, Ativan 2mg IM “now”, and Benadryl 50mg IM “now” were given for an emergency medical situation. The EMR did not include documentation of the effectiveness of the medications administered. Review of the “MAR” dated 10/06/25 at 5:04 PM, located in the EMR under the “Table of Contents” tab revealed NP1 ordered onetime telephone orders for Ativan 2mg oral, Benadryl 200mg oral, and Thorazine 200mg oral was administered for agitation. Review of P6’s EMR with Registered Nurse (RN) 2 and Lead Case Manager (LCM) 1 on 01/19/26 did not reveal face to face evaluations were conducted within one hour after the use of chemical restraints on 10/06/25 at 12:28 AM, 10/05/25 at 3:36 AM, and 10/06/25 at 5:04 PM. During an interview on 01/21/26 at 1:00 PM, RN3 stated the RN Supervisors are responsible to conduct the face to face evaluation of a patient after a chemical restraint is used. During an interview on 01/21/26 at 3:15 PM, RN7 state he/she was the RN Supervisor on 10/05/25 into 10/06/25 for the 7:00 PM to 7:00 AM shift. RN7 confirmed a face to face evaluation was not conducted of P6 after the use of chemical restraints on 10/06/25 at 12:28 AM and 10/06/25 at 3:36 AM. During an interview on 01/22/26 at 11:25 AM, RN5 stated he/she was the RN Supervisor on 10/06/25 for the 7:00 AM to 7:00 PM shift. RN5 confirmed a face to face evaluation of P6 was not conducted after the use of chemical restraints on 10/05/25 at 5:04 PM. Review of the hospital policy titled, “Seclusion and Physical Restraint” revised on 12/05/25 revealed, “ ... A psychoactive medication that is used to treat increased, sudden onset of symptoms of a mental illness that have escalated to a psychiatric emergency, requiring emergent intervention with a medication that has not been planned in advance, is ordered as a one-time “now” dose, is declined by the patient and is intended to alleviate the sudden onset of symptoms without immobilizing the patient. Emergency medications fall under the guidelines of restraint and seclusion and shall be documented accordingly and include a face-to-face evaluation within one hour of administration ...A physician, physician assistant or registered nurse who has proven training and competence in conducting face-to-face evaluations associated with restraint and seclusion, shall conduct a face-to-face evaluation of the patient within one hour of the initiation of a restraint or seclusion. to verily the need for the intervention ....””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iii) [there must be documentation in the patient’s medical record of] Alternatives or other less restrictive interventions attempted (as applicable); This Standard is not met as evidenced by: 17281 Based on medical record review, interviews, and policy review, the hospital failed to use chemical restraints only after less restrictive interventions were tried and ineffective for one of three (Patient (P6 ) reviewed for the use of chemical restraint out of a total sample of 10 patients. This failure had the potential to affect any patient in the hospital that required the use of a chemical restraint. Findings include: Review of P6’s “Face Sheet” located in the EMR under the “Table of Contents” tab revealed P6 was admitted to the hospital on 10/05/25 with diagnoses that included schizoaffective disorder and type 1 diabetes mellitus. Review of the “Initial Psychiatric Evaluation Acute” dated 10/05/25 located in the EMR under the “Table of Contents” tab revealed, “ ...The patient is a 37year old [male/female] admitted via involuntary commitment due to marked behavioral changes and bizarre conduct observed both at home and in the facility ...The patient’s psychiatric history is significant for schizophrenia, schizoaffective disorder (bipolar type) ...Hospitalization will provide the structure, monitoring, and medication management needed to stabilize his condition and ensure the safety of both the patient and those around him ....” Review of the “MAR” dated 10/06/25 at 5:04 PM, located in the EMR under the “Orders” tab revealed onetime telephone orders for Ativan (medication used for anxiety) 2 milligram (mg) oral, Benadryl (used for sedation) 200mg oral, and Thorazine (medication used for mental illness) 200mg oral were administered for agitation. Review of P6’s EMR on 01/19/26 with Registered Nurse (RN) 2 and Lead Case Manager (LCM) 1 failed to reveal documentation less restrictive measures were tried or were ineffective before P6 received chemical restraints on 10/06/25 at 5:04 PM. The EMR did not reveal a justification for not attempting less restrictive interventions. During an interview on 01/21/26 at 1:00 PM, RN3 stated he/she was the nurse on 10/06/25 for the 7:00 AM to 7:00 PM shift. RN3 confirmed less restrictive measures were not tried prior to P6 receiving chemical restraints on 10/06/25 at 5:04 PM. Review of the hospital policy titled, “Seclusion and Physical Restraint” revised on 12/05/25 revealed, “ ... I . The RN shall review the documentation received from Intake to familiarize self and staff with issues related to the patient’s needs respective to restraint and seclusion. 2.The RN shall ensure that staff on duty are aware of the patient’s status and utilize the least restrictive interventions and strategies identified in the initial assessment to attempt to prevent a psychiatric emergency should signs and symptoms present, to include but not limited to; a. Use of verbal de-escalation b. Engaging patient in l:l interaction c. Offering comfort measures such as food, drink, or blanket d. Offering PRN medication if available e. Encouraging patients to go to their room or a quiet area if appropriate 3. The RN must document all interventions which were employed in attempt to prevent a psychiatric emergency, the patient’s response to the interventions attempted or the justification for not attempting such interventions ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. This Standard is not met as evidenced by: 17281 Based on record review, interview, and policy review, the hospital failed to ensure staff assessment for the use of chemical restraints was conducted for one of three (Patient (P6 ) reviewed for the use of chemical restraints out of a total sample of 10 patients. This failure had the potential to affect any patient in the hospital that required the use of a chemical restraint. Findings include: Review of P6’s “Face Sheet” located in the EMR under the “Table of Contents” tab revealed P6 was admitted to the hospital on 10/05/25 with diagnoses that included schizoaffective disorder and type 1 diabetes mellitus. Review of the “Initial Psychiatric Evaluation Acute” dated 10/05/25 located in the EMR under the “Table of Contents” tab revealed, “ ...The patient is a 37 year old [male/female] admitted via involuntary commitment due to marked behavioral changes and bizarre conduct observed both at home and in the facility ...The patient’s psychiatric history is significant for schizophrenia, schizoaffective disorder (bipolar type) ...Hospitalization will provide the structure, monitoring, and medication management needed to stabilize his condition and ensure the safety of both the patient and those around him ....” Review of the nurse “Narrative Note” dated 10/06/25 at 3:36 AM, located in the EMR under the “Table of Contents” tab revealed, “ ...Pt [patient] is irritable after roommate waking him up. Pt is hitting all the doors of the unit- Pt threw water at staff.” Review of the “Medication Record (MAR)” dated 10/06/25 at 3:36 AM located in the EMR under the “Order” tab revealed, Haldol (medication to treat mental illness) 10 milligram (mg) intramuscular (IM) “now”, Ativan (used for anxiety) 2mg IM “now”, and Benadryl (sedative) 50mg IM “now” were given for an emergency medical situation. Review of the “MAR” dated 10/06/25 at 5:04 PM, located in the EMR under the “Orders” tab revealed onetime telephone orders for Ativan 2mg oral, Benadryl 200mg oral, and Thorazine (medication used for mental illness) 200mg oral was administered for agitation. Review of P6’s EMR on 01/19/26 with Registered Nurse (RN) 2 and Lead Case Manager (LCM) 1 did not reveal a staff debrief to evaluate P6’s response and impact of the use of chemical restraints on 10/06/25 at 3:36 AM and 10/06/25 at 5:04 PM were conducted. During an interview on 01/20/26 at 4:15 PM, RN8 stated he/she was the nurse on 06/06/25 for the 7:00 PM to 7:00 AM shift. RN8 confirmed a staff debrief to review the chemical restraint event was not held after chemical restraint was used on 10/06/25 at 3:35 AM. During an interview on 01/21/26 at 1:00 PM, RN3 stated he/she was the nurse on 10/06/25 for the 7:00 AM to 7:00 PM shift. RN3 confirmed a staff debrief to evaluate P6’s response to the chemical restraint used on 10/06/25 at 5:04 PM was not conducted. Review of the hospital policy titled, “Seclusion and Physical Restraint” revised on 12/05/25 revealed, “ ... A psychoactive medication that is used to treat increased, sudden onset of symptoms of a mental illness that have escalated to a psychiatric emergency, requiring emergent intervention with a medication that has not been planned in advance, is ordered as a one-time “now” dose, is declined by the patient and is intended to alleviate the sudden onset of symptoms without immobilizing the patient. Emergency medications fall under the guidelines of restraint and seclusion and shall be documented accordingly ... Staff debriefing is conducted as soon as possible but no later than the end of the shift, the RN or RN Supervisor will meet with the staff involved in the event to review the events and response to the event to include: l) Evaluation of the management of the situation to include identification of problems or need for modifications in managing the situation or success of the intervention a) Precipitating triggers and signs of impending behavior b) De-escalation techniques used c) Interventions that may be employed to prevent similar situations from developing with the individual patient 2) identification of any injuries sustained by staff 3) clinically indicated or upon the request of other individuals who witnessed a restraint the staff shall have a private discussion with said witness 4) Staff shall document the staff debriefing in the designated form and tum the document into nursing administration ...””

“PHARMACY PERSONNEL CFR(s): 482.25(a)(2) The pharmaceutical service must have an adequate number of personnel to ensure quality pharmaceutical services, including emergency services. This Standard is not met as evidenced by: 17281 Based on record review, interview, and policy review, the hospital failed to ensure the pharmacist provided supervision when Stat (give immediately) telephone medication orders were received after pharmacy hours for one of three (Patient (P) 6) reviewed for chemical restraints in a total sample of 10 patients. This failure had the potential to affect any patient in the hospital who required a Stat telephone medication order after pharmacy hours. Findings include: Review of P6’s “Face Sheet” located in the EMR under the “Table of Contents” tab revealed P6 was admitted to the hospital on 10/05/25 with diagnoses that included schizoaffective disorder and type 1 diabetes mellitus. Review of the “Initial Psychiatric Evaluation Acute” dated 10/05/25 located in the EMR under the “Table of Contents” tab revealed, “ ...The patient is a 37 year old [male/female] admitted via involuntary commitment due to marked behavioral changes and bizarre conduct observed both at home and in the facility ...The patient’s psychiatric history is significant for schizophrenia, schizoaffective disorder (bipolar type) ...Hospitalization will provide the structure, monitoring, and medication management needed to stabilize his condition and ensure the safety of both the patient and those around him ....” Review of the “MAR” dated 10/06/25 at 5:04 PM, located in the EMR under the “Orders” tab revealed onetime Stat telephone orders for Ativan (medication for anxiety) 2 milligrams (mg) oral, Benadryl (medication used for sedation) 200mg oral, and Thorazine (medication used for mental illness) 200mg oral was administered for agitation. Review of the “MAR” dated 10/06/25 at 6:44 PM, located in the EMR under the “Orders” tab revealed onetime telephone orders for Thorazine 200mg (intramuscular) IM, Versed 5mg (a powerful medication used in medical settings for sedation) IM, and Benadryl 200mg IM were administered to P6 for agitation. Review of P6’s EMR on 01/19/26 from 3:00 PM through 4:30 PM with Lead Case Manager (LCM) 1 and Registered Nurse (RN) 2 failed to reveal documentation the pharmacist alerted staff of the polypharmacy and possible contraindications of the ordered medications on 10/06/25 at 5:04 PM and 6:44 PM. During an interview on 01/20/26 at 11:42 AM, RPh 1 stated the hospital pharmacy is open Monday through Friday from 8:00 AM to 3:00 PM and on weekends from 8:00 AM to 2:00 PM. An on-call pharmacy provides services after hours. If there are any prescriptions that need to be verified after hours they are verified off-site. RPh 1 stated medications for administration to patients are stored in the Omni Cell on each unit. If there are verbal, telephone, or Stat (emergency) medication orders after hours that are not in the Omni Cell, the nurse can call the remote pharmacy. Stat orders ordered after hours require the nurse to call the remote pharmacy. RPh 1 stated if during pharmacy hours there is a concern with prescribed medications including Stat medications; he/she speaks directly to the provider not the nurse. RPh 1 stated administering Versed, Benadryl, and Thorazine together would cause sedation and the onetime Stat medications ordered and administered on 10/06/25 at 5:04 PM and 6:44 PM were not reviewed by the Pharmacist. RPh 1 stated if he/she was aware of the onetime only Stat medication orders on 10/06/25 at 5:04 PM and 6:44 PM, the provider would have been contacted to inform him/her of the concern that the amount of medication was “too much and too soon” because the orders were only one hour and 40 minutes apart. RPh 1 confirmed the remote pharmacist was not notified of the Stat medications and did not provide consultation with the provider. Review of the hospital policy titled, “The Role of The Pharmacist in the Drug Distribution System with On-Site Nursing Units” revised 07/25 revealed, “ ... All pharmacists will be responsible for drug therapy interventions upon order entry. The RPh will record interventions through the department’s Continuous Quality Improvement system, in the patient’s medical record, or with the individual drug order itself. The Pharmacist is responsible for consulting with the prescriber for significant drug incompatibilities, food-drug incompatibilities, excessive polypharmacy, and missing or known drug allergies. The medication will not be dispensed until the order has been clarified. ln addition, all incomplete or unclear orders will be clarified prior to dispensing. Evaluation of the scope and extent of documented interventions will contribute to the pharmacist’s performance evaluation ....””

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 25065 Based on interview, record review, and policy review, the hospital failed to ensure appropriate arrangements were made to discharge a patient to a safe environment prior to discharge when the patient’s parent stated he/she could not provide care for one (Patient (P) 4) of three patient records reviewed for discharge planning from a total sample of 10 patients. This deficient practice had the potential for patients to be discharged post-hospital care to an unsafe environment. Findings include: Review of P4’s electronic medical record (EMR), under the heading that appeared when patient’s name was typed in, indicated P4 was admitted involuntarily on 08/13/25 with diagnoses of gastro-esophageal reflux disease (GERD) without esophagitis, hyperlipidemia, unspecified, schizoaffective disorder, bipolar type, and essential (primary) hypertension. Review of P4’s “Order on Application For Appointment of Guardian” revealed P4’s mother was granted guardianship on 07/08/23. Review of the “Intake Assessment,” located under the “”Intake Assessment Acute” tab of the EMR, documented on 08/13/25 at 2:00 PM P4 was transferred from the emergency department of an acute care hospital for involuntary commitment. Further review indicated P4 lived in a group home and had been aggressive, disrobing, and threatening. It was indicated P4 reported depression, anxiety, and paranoia. P4 was triaged as a low suicide risk, and P4’s group home was listed as P4’s patient support. Review of P4’s “Initial Psychiatric Assessment Acute,” located under the “Table of Contents” tab of the EMR and documented by Psychiatric Mental Health Nurse Practitioner (NP) 1 on 08/14/25 at 5:19 PM, indicated discharge planning would begin early in P4’s admission with collaboration among the patient, P4’s group home, outpatient mental health providers, and family or other support systems to ensure a safe and coordinated transition of care. Review indicated P4’s mother was not willing to be involved in P4’s treatment. Review indicated P4’s current living situation was a group home. Documentation indicated “Unknown” when P4 was asked if he/she would return there. Review of P4’s “Psychosocial Assessment,” located under the “Table of Contents” tab, then the “Psychosocial Assessment” tab of the EMR and documented by Licensed Clinical Social Worker Associate (LCSW) 2 on 08/14/25 at 12:22 PM, indicated the preliminary discharge plan was to return to the previous living arrangement and attend outpatient therapy. Review of P4’s “Psychiatric Progress Notes,” located under the “Table of Contents” tab, then under “Narrative Note” tab of the EMR and documented by NP1 revealed: 08/19/25 at 9:00 AM - “. . . We are awaiting confirmation of an appropriate placement, as the patient is not suitable for a shelter and remains at risk for harm-[his/her] intrusive behavior could provoke negative responses from others. This ongoing intrusiveness underscores [his/her] need for continued hospitalization, as it would likely lead to problematic interactions with peers in a community setting. According to case management, [he/she] is not allowed to return to [his/her] previous group home. We will continue searching for suitable alternatives to ensure [his/her] compliance within the community and provide a structured environment. . .” 08/27/25 at 1:34 PM - “. . . [He/She] is scheduled for an assisted living facility assessment tomorrow, with the goal of finding a structured environment to support ongoing care including medication administration and reduce the risk of rapid readmission, as [he/she] is not appropriate for shelter care and lacks community support or alternative housing. . .” 08/28/25 at 1:51 PM - “. . . [He/She] reported that [he/she] wants to go home. . .” 09/01/25 at 1:53 PM - “. . . Continued monitoring until discharge is arranged, [he/she] is scheduled to return to [his/her] mother’s home tomorrow until community placement can be secured. . .” Review of P4’s “Narrative Notes”, located under the “Table of Contents” tab, then under “Narrative Note” tab of the EMR, revealed: 08/18/25 at 9:20 AM by LCSW3 - Guardian “reported patient has been living at the Group home . . . [He/She] stated this behavior is not normal for pt [patient] and believes [he/she] was being provoked by someone to destroy property and charge at staff and residents. [He/She] reported patient was hospitalizes [sic] 4-5 [four to five] months ago for similar behaviors. [He/She] reported patient does not feel comfortable at the group home due to having limited family supports around . . .” 08/19/25 at 9:01 AM by LCSW3 - administrator of group home “. . . reported [he/she] does not want to accept the patient back. Clinician asked if 30 day notice was provided to the Legal guardian. [He/She] reported ‘yes’. . .” 08/19/25 at 9:09 AM by LCSW3 - P4’s legal guardian stated no official 30 day notice provided to [him/her]. P4’s legal guardian confirmed rent was paid for the month of August. 08/19/25 at 10:48 AM by LCSW3 - LCSW3 contacted the group home administrator and reported that P4 “will be discharging tomorrow back to the group. Clinician stated LG [legal guardian] reported not receiving a 30 day notice and has paid rent for the month of August. [name of administrator of group home] was unable to verify and stated [his/her] father handles that business. Clinician [stated] patient has been a resident at there [sic] facility for 4-5 [four to five] years and they would be required to go through the official channels with coordinating with the LG and other officials for the removal of the patient. Clinician stated patient will be escorted by Law enforcement to the facility.” 08/19/25 at 10:50 AM by LCSW3 - attempted to contact P4’s legal guardian (parent) and left voice mail. 08/21/25 at 3:55 PM by Clinical Director (CD) - “DCS [Director of Clinical Services - same as Clinical Director] called group home director [name of director] and left a detailed message that stated we would like to understand their concerns wrt [with relations to] to discharging [his/her] residents. This writer informed [name of director] that [his/her] residents have been clinically cleared and are ready to return to [his/her] GH [group home] - but we needed to confirm to ensure a safe discharge. DCS informed [name of director] that the tx [treatment] team has set [his/her] resident’s discharge for Monday 25 August with the plan for [him/her] to return to [his/her] GH where [he/she] has resided for 4yrs [four years]. Advised [him/her] to call RO [initials of hospital] [sic] further discussion if there is a legitimate clinical reason for them to continue to stay with us.” 08/27/25 at 3:09 PM by LCSW3 - informed legal guardian “. . . of group home interview on tomorrow at 11am [11:00 AM] and will follow up with [him/her] after the interview.” 08/28/25 at 12:46 PM by LCSW3 - “. . . accompanied patient with group home interview with [name of person at group home] at 12pm [12”00 PM].” 08/28/25 at 4:17 PM by LCSW3 - person from group who conducted the interview on 08/28/25 at 12:00 PM reported “will accept patient into [his/her] group home. . .” 08/29/25 at 4:39 PM by LCSW3 - received a call from person from group who conducted the interview on 08/28/25 at 12:00 PM who “. . . reported changing [his/her] mind and feeling patient will not be a good fit for group home after speaking with [his/her] [parent] (Legal guardian). [He/She] feels there will be conflict and issues in the future.” 08/29/16 at 4:16 PM by Lead Case Manager (LCM) 1 - “. . . spoke with PT [patient] [parent]/legal guardian to notify of discharge plan. CM [case manager] explained that PT is no longer a harm to [himself/herself] and has been clinically cleared and will need to discharge to their care. Mother confirmed home address . . .” 09/02/25 at 9:49 AM by LCM1 - “CM spoke with PT legal guardian this morning who stated PT cannot stay at home with [him/her] and would like for PT to be admitted into [name of state hospital]. CM explained that as the legal guardian they can sign the PT into another facility and/or pursue community placement after discharge from [name of hospital] . . . Sheriff transport has been arranged and will return PT to [his/her] legal guardian . . .” Review of P4’s “Discharge Continuing Care Plan Assessment,” signed by LCSW3 on 08/21/25 at 3:43 PM, indicated it was reviewed with P4 and P4’s legal guardian, discharge address was listed as address of legal guardian, and transportation would be provided by law enforcement. A follow-up appointment was scheduled with behavioral health for 09/04/25 at 9:00 AM. Review of P4’s “Discharge Summary Acute,” documented by NP1 on 09/04/25 at 3:19 PM indicated, “. . . On the day of discharge, the patient was evaluated by the provider and was discussed with the multidisciplinary treatment team. A [sic] day of discharge assessment included a suicide risk and violence risk assessment. At the time of discharge, the treatment team determined that the patient was stable, posed no acute risk of dangerousness to self or others and was appropriate for discharge. A follow-up plan and crisis plan were put in place and were discussed with the patient, Safety plan was coordinated via care coordination . . . Further, the patient is assessed to be appropriate for discharge from the inpatient setting as condition has reached the point where continued care, diagnostic refinement, and treatment can be reasonably and safely performed in a lesser restrictive setting. It was recommended that the patient continue outpatient mental health treatment in the community as well as routine medical health care in the community after discharge with appointments scheduled. Bridging prescriptions for needed medications were provided until the patient can be see [sic] for hospital discharge follow-up appointments. . .” Patient disposition was documented as “Home.” Review of P4’s “Discharge Notification,” signed by the Registered Nurse and P4 indicated P4 was discharged on 09/02/25 at 11:00 AM to the address of P4’s legal guardian (parent). Review of P4’s EMR indicated P4 was discharged to P4’s legal guardian’s home (parent) when P4’s legal guardian had reported on 09/02/25 at 9:49 AM that P4 could not stay with [him/her]. There was no documentation of further attempts to identify a safe environment for the discharge of P4 after the discharge planning staff received report on 08/29/25 at 4:39 PM that the second group home had refused to accept P4. During an interview on 01/19/26 at 1:48 PM, CD stated when the case manager has difficulty with a group home refusing to accept patients after discharge, the case manager elevates the call to CD to handle. CD stated there are strict guidelines confirming the location of discharge before a patient is discharged. When asked if they have a protocol that addresses law enforcement having to wait until a patient enters a home or have someone to meet them before leaving, CD stated it would be assumed that would be done. CD stated each county has their own rules about transport. CD stated if a patient is left outside by law enforcement without seeing the patient enter the home or without seeing someone come to receive the patient, it could be viewed as discharging in an unsafe situation. During an interview on 01/19/26 at 2:15 PM, LCM1 stated P4’s parent (legal guardian) stated P4 could not stay at his/her home. When asked how it was safe to discharge P4 home when his/her legal guardian (parent) stated P4 couldn’t stay there, LCM1 stated the hospital could not pursue sending P4 to another acute care provider based on NP1’s documentation that P4 was no longer a harm to himself/herself and had been clinically cleared for discharge to P4’s parent’s care. LCM1 confirmed no further attempts were made to locate a group home after the second group home refused to accept P4. LCM1 confirmed P4 was discharged to P4’s legal guardian’s (parent) home, although P4’s legal guardian told LCM1 the day of discharge that P4 could not stay with him/her. An unsuccessful attempt was made to interview LCSW3 during the survey. LCSW3 was ill and unavailable to be interviewed. Review of the hospital’s policy titled, “Discharge and Continuing Care Planning,” effective and approved by the Governing Body on 08/02/22, indicated discharge planning was “. . . an organized, coordinated process, with multidisciplinary team, patient and family input, identifies the patient’s needs after discharge, delineates plans to meet these needs and teaches the patient and family how to implement the plans . . . Discharge planning is continued and formalized in Interdisciplinary Treatment Team meeting where estimated length of stay and projected date of discharge is discussed with treatment team members . . . The therapist is responsible for coordinating the discharge plan. All members of the interdisciplinary treatment team are responsible for input to therapist, providing necessary and pertinent information regarding the patient’s status and needs to assist therapist in facilitating discharge planning. The final discharge plan will be communicated to identify parties in the discharge plan in a timely manner . . . Notice of discharge shall be provided to the individual or the individual’s legal representative in a timely manner in advance of the discharge. . . Discharge shall be coordinated with the individual, and, with permission, the individual’s family, legal representative, or appropriate agency, in a timely manner.” Review of the hospital’s undated “Case Management/Discharge Planning,” presented by CD as documentation of the discharge process by staff role, indicated “. . . Ensure legal guardians are informed of discharge PRIOR to discharge. A patient cannot discharge without first notifying the pt’s LG (they do not necessarily need to agree, but they do have to be informed) . . . “”

“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: 17281 Based on record review, acute record review, interview, and policy review, the hospital failed to ensure the medical record included progress note documentation that represented the patient’s status, response to treatment provided, and a chronological timeline during a crisis situation for one of three (Patient (P) 6) patients reviewed for chemical restraints. The hospital’s failure to ensure the medical record contained information on actual events the patient experienced and outcomes of treatment in the hospital had the potential to affect all patients receiving care in the hospital. Findings include: Review of P6’s “Face Sheet” located in the electronic medical record (EMR) under the “Table of Contents” tab revealed P6 was admitted to the hospital on 10/05/25 with diagnoses that included schizoaffective disorder and type 1 diabetes mellitus. Review of the “Initial Psychiatric Evaluation Acute” dated 10/05/25 located in the EMR under the “Table of Contents” tab revealed, “ ...The patient is a 37 year old [male/female] admitted via involuntary commitment due to marked behavioral changes and bizarre conduct observed both at home and in the facility ...The patient’s psychiatric history is significant for schizophrenia, schizoaffective disorder (bipolar type) ...Hospitalization will provide the structure, monitoring, and medication management needed to stabilize [his/her] condition and ensure the safety of both the patient and those around [him/her] ....” Review of the “Medication Administration Record (MAR)” dated 10/06/25 at 5:04 PM, located in the EMR under the “Order” tab revealed onetime Stat (give at once) telephone orders for Ativan 2mg (medication used to treat anxiety) oral, Benadryl 200mg (sedative) oral, and Thorazine 200mg (medication used to treat severe mental health conditions) oral were administered for agitation. Review of the “MAR” dated 10/06/25 at 6:44 PM, located in the EMR under the “Orders” tab revealed onetime Stat telephone orders for Thorazine 200mg (intramuscular) IM, Versed 5mg (a powerful medication used in medical settings for sedation) IM, and Benadryl 200mg IM were administered to P6 for agitation. Review of the “Critical Care Note” located in P6’s acute care hospital EMR revealed, “ ... Patient is coming from [hospital name]. Patient had arrived at facility [psychiatric hospital] on the night of 10/05/25. Per EMS [Emergency Medical Services] report, staff at facility stated that [his/her] blood glucose levels were running high, gave [him/her] an extra dose of insulin. They observed that patient got agitated on the phone, became combative with the facility staff. In an attempt to calm patient down, staff gave pt 5mg Versed IM, 200mg Thorazine IM, and 200mg of Benadryl IM and called for EMS due to pt [patient] being combative. [name local police] also responded and when they arrived at the facility, they advised that pt was in cardiac arrest. Cardiopulmonary Resuscitation (CPR) started by facility staff along with O2 [oxygen] by BVM [bag value mask]. EMS found patient lying on floor with adequate CPR and ventilations. Initial rhythm on monitor was PEA [pulseless electrical activity]. They attempted to pace several times with no capture. After several rounds of CPR and meds, patient converted to V-Tach [rapid heartbeat above 100 beats per minute] and was shocked once. After shock, patient regained pulses with irregular bradycardia [slow heartrate]. Pacing attempted again with capture and patient maintained pulses. Was transferred to the ED at [acute care hospital name] on 10/06/25 ...admitted to the Medical Intensive Care Unit (MICU) with cardiac failure, circulatory failure, respiratory failure, renal failure, and Central Nervous System (CNS) failure ....” Review of P6’s EMR on 01/19/26 from 3:00 PM through 4:30 PM with Lead Case Manager (LCM) 1 and Registered Nurse (RN) 2 failed to reveal the EMR included any documentation of progress notes or assessments by RN 3 who was assigned to provide care to P6 on 10/06/25 for the 7 AM -7 PM shift. The EMR failed to include any documentation of the sequence of events that led to P6 receiving chemical restraints on 10/06/25 at 5:04 PM and 6:44 PM, the communication provided to Nurse Practitioner (NP) 1 on 10/06/25 at 5:04 PM and 6:44 PM to warrant orders for chemical restraints. The EMR failed to reveal documentation of the sequence of events that led to P6 becoming pulseless and without respirations, initiation of CPR, EMS arrival and P6 being transferred to the acute care hospital. Review of P6’s EMR failed to include any documentation an assessment was conducted or vital signs obtained after medications were administered on 10/06/25 at 5:04 PM and 10/06/25 at 6:44 PM. Review of the hospital policy titled, “Seclusion and Physical Restraint revised 12/05/25 revealed, “ ...Documentation: Patient Medical Record - The following information shall be recorded in the patient’s medical record for each episode of restraint and/or seclusion: A physician order as specified in section C-4 above, b. Completion of the designated form for use in restraint and seclusion, which includes at least the following: The type of intervention used, the name of the physician authorizing the intervention, the date and time the intervention began and terminated, the name of the staff initiating the intervention, with signature, date, time and credential of the staff, the name, title and credential of all staff present at the beginning of the intervention and witnesses, the role of each staff member involved in the intervention, to include roles during the intervention. to include positions and observer roles, the continuous observation of the patient must be documented (q.15) throughout the intervention, the times of additional interventions and assessments conducted during the restraint or seclusion, the least restrictive measures attempted prior to the intervention and the response to said interventions, the patient’s response to the restraint or seclusion, if the patient refuses to participate in any part of the required assessment, the refusal must be documented. along with continued attempts to complete the assessment. Progress Notes: A progress note must be written corresponding with the event by the RN ....” Review of the hospital policy titled, “Code Blue” effective date 12/18/25 revealed, “ ... All events surrounding the emergency will be documented in the patient’s medical record ....””