Central Desert Behavioral Health Hospital

“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: 53401 Based on record review and interview, the facility failed to obtain the proper consent for newly ordered psychotropic medications for 1 (P[patient] 5) of 4 patients (P5- and P8) patients reviewed. The facility also failed to ensure consent was obtained prior to administration of these medications. This deficient practice has the potential to affect patient health, safety, and rights. The findings are: A. Record review of the facility’s policy titled, “Medication Consent for Psychiatric Medications”, with a revised date of 04/19/23, stated, “Informed consent is the process whereby the prescribing practitioner assures that the patient (or patient’s guardian/ legal representative) has received information about a proposed medication/treatment ...” B. During an interview on 04/14/26 at 09:15 AM, P5’s legal representative, who is also a family member, informed the surveyor that P5 is developmentally delayed, Autistic, and is high functioning. The legal representative confirmed that he is the legal guardian for P5. C. During an interview of 04/14/26 at 09:45 AM, P5’s legal representative provided the surveyor with documentation verifying legal guardianship. D. Record review of P5’s medical record for the admission dated 09/30/25, showed a document titled, “Consent for Psychiatric Medications” that was signed by P5 rather the legal guardian. The facility failed to follow its own policy requiring consent from the legal representative. E. During an interview on 04/15/26 at 2:17 PM with staff (S) 9, the surveyor was informed of the process for a new psychotropic medication order. S9 reported that when a new psychotropic medication is ordered, an icon appears next to the medication, directing staff to the physician’s orders for acknowledgement. Additionally, S9 stated that before administration, the nurse is prompted to access go to clinical doc, and then to PDF forms, which leads to the psychotropic consent form. The nurse fills out the consent form, informs the patient/legal guardian about the new medication, and obtains an electronic signature. However, this process was not followed according to the policy, as the document titled, “Consent for Psychiatric Medications” document was signed by P5 and S9, rather by the legal guardian.”

“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: 53401 A-0144- The patient has the right to receive care in a safe setting. Based on record review and interview, the facility failed to ensure that patients legal guardianship status was clearly identifiable for 1(P[patient]5) out of 4 (P5-P8) patients reviewed. This deficient practice has the potential to place patient safety at risk for adverse outcomes. The findings are: A. Record review of P5’s medical record for admission dated 09/30/25, revealed that the patient’s legal guardianship status was not displayed on the chart “banner”. B. Record request of legal guardianship documentation for P5 revealed the facility was unable to provide the required paperwork. C. During an interview on 4/14/26 at 10:20 AM with staff (S) 4, clinical, the surveyor asked how staff determine whether a patient has a legal representative. S4 stated the information appears on the patient’s EPIC “dashboard after the facility receives the legal documentation. Furthermore, when guardianship documentation was not found in the EMR, S4 stated the paperwork “it could have been in the paper chart which is kept at the nurse’s station” and that the documents should be scanned into the chart after the patient is discharged.”

“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: 53401 Based on record review and interviews, the facility failed to ensure that nursing staff followed policies and procedures for obtaining consent for psychotropic medications prior to their administration, for 1(P[patient]5) out of 4 (P5-P8) patients reviewed. This deficient practice has the potential to place patient safety at risk for adverse outcomes. The findings are: A. Refer to Tag A-0131”

“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: 47302 Based on record review and staff interview, the facility failed to monitor withdrawal symptoms using COWS (Clinical Opiate Withdrawal Scale) protocol for 1 (P [patient]1) out of 3 (P1 - P3) patient reviewed. This deficient practice could lead to patient’s withdrawal symptoms not being managed and lead to increased discomfort for patients. The findings are: A. Record review of the facility’s policy titled, “Opiate/Heroin [substances derived from opium plant] Withdrawal Protocol” dated 04/2022 under “Definition” stated, “Opiate withdrawal syndrome is generally not life threatening. Withdrawals are characterized by hypertension (high blood pressure), tachycardia [increased heart rate], agitation [restless anxiety], tremulousness [shaking or trembling] and anxiety. Onset of withdrawal usually coincides with the time of the next habitual drug dose.” Under, “Subjective complaints” stated, “Pt [patient] states withdrawing from ..... (opiate, heroin) - Use of opiate for more than 3 weeks ...” Under “Plan” stated, “ ...Tylenol [over the counter pain medication] 650 mg [milligrams] prn [as needed] [every] 6 hours - Complete COWS score 1 [time] daily for 3 days-patient can stay in general population - Reassure - Fluids, electrolyte replacement/rest/clear liquid diet if needed.” B. Record review of P1’s medical record for admission on 12/2/2024 revealed the following: 1. Under, “Admission Data” there was a table titled, “Substance Use Withdrawal Symptoms” indicated in this table that P1 was having withdrawal symptoms of nausea, tremors, agitation and irritability. 2. P1’s “History [and] Physical” dated 12/3/2024 stated, “[Patient] with a history of depression who was taken to the ER [emergency room] after a suicidal attempt. According to the report the patient took a bunch of pills. Reports stated P1 took 8-10 oxycodone [opiate pain medication] of 20 mg tablets and 320 mg OxyContin [long-acting opiate] tablets while drinking champagne. The patient was given Narcan [opiate reversal medication] by his wife ...” 3. P1’s “Psychiatric Progress Note” dated 12/06/2024 at 3:02 AM revealed “ ...The patient feeling miserable due to withdrawal symptoms from oxycodone and ongoing pain. He shared that he had been on oxycodone for 15 years before being abruptly discontinued, with his last dose taken on Monday...” 4. P1’s medical record revealed the record did not contain a COWS score was performed on P1 during admission. The record did not contain a withdrawal assessment from 12/3/2024 through 12/6/2024. C. During an interview on 04/15/2025 at 1:20 PM with S(staff)5, clinical, it was explained that the COWS protocol would be implemented for a patient that was on chronic opiate (increasing heavy or frequent use) medications prior to being admitted. D. During an interview on 04/15/2025 at 3:00 PM with S7, clinical, it was explained that patients coming with a history of opioid abuse should be monitored for withdrawal.”

“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: 47302 Based on record review and interview the facility failed to ensure that wounds were reported to the provider and failed to ensure wound care was being done on 1 (P [patient] 11) of 10 (P11-P20) patients reviewed for wound assessment and care. This deficient could lead to worsening of wounds, infection and decline in patient’s health. The findings are: A. Record review of facility’s policy titled, “Evaluation” dated 07/2012 under “Procedures” it stated, “Evaluation is the formal process in which wound characteristics, underlying conditions and contributory medical history are identified/quantified. Evaluation should result in treatment approaches including elimination or compensation for causative factors and a prognosis for healing. . . 3. Evaluation results are communicated to the members of the care team through documentation, case conference, and care planning. 4. Treatments should also be re-evaluated every 2 - 3 weeks. If no wound progression noted treatment change should be considered. If no change in treatment done documentation should occur as to why current treatment maintained.” B. Record review of facility’s policy titled, “Wound Documentation” dated 07/2012 under “Procedures” it stated, “1. Documentation about the wound provides valuable information about wound progress or lack of progress. 2. On admission and/or discovery, the clinician initiates the wound document process. . .” C. Record review of a nursing admission note for P11 on 10/03/2024 at 4:23 PM stated, “Skin assessment performed. Pt [patient] has skin tears on L [left] elbow, R [right] wrist and hand and R forearm and wrist. Abrasion [scrape] in middle of back, running next to spine. Pressure ulcer [localized damage to skin related to pressure] on coccyx [base of spinal column, also known as the tailbone] that appears red and sloughing skin [skin that is coming off].” D. Record review of provider admission note for P11 on admission date 10/03/2024 does not reveal evidence that provider noted the wounds or was made aware of P11’s wounds. E. Record review of orders for P11 did not reveal any wound care orders for patient’s wounds. F. Record review of the discharge skin assessment for discharge date 11/10/2024 revealed a diagram that noted the abrasion in the middle of the patient’s back and pressure ulcer on the patient’s coccyx. G. During an interview with Staff (S)6, Registered Nurse on 03/14/2024 at 2:07 PM it was asked what the wound care process was for the facility, S6 stated they notify the provider to assess it and put orders in. S6 stated they chart wound care in shift notes. H. During an interview with S1, Chief Nursing Officer on 03/14/2024 at 3:15 PM it was confirmed that there was no wound care orders or wound care done for P11. S1 confirmed that the provider should have been notified and that would be evident in the documentation and orders.”