Haven Behavioral Hospital of Dayton

“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: 42492 Based on medical record review, interview, and policy review, the facility failed to notify the patient representative of a change in patient condition. This affected one (Patient #4) of fifteen patients sampled for patient rights. The facility census was 54. Findings include: Review of the medical record revealed Patient #4 was involuntarily admitted to the hospital on 12/30/25 from a Skilled Nursing Facility (SNF) with an admitting diagnosis of major depressive disorder. He was discharged back to his former SNF per family request on 01/09/26. Review of a Nutritional Screening Assessment dated 12/30/25 revealed Patient #4 had no significant weight history, dietary behaviors within normal limits, no significant medical conditions, no nutrition risk factors, and no chewing/swallowing issues. Review of progress note dated 12/31/25 at 12:45 P.M. revealed Patient #4 would not attend all meals. Review of progress note dated 01/05/26 at 2:08 P.M. revealed Patient #4 was alert to self and attended meals but had poor intake. Staff educated Patient #4 to the importance of eating and taking medications. Review of progress note dated 01/06/26 at 11:56 P.M. revealed Patient #4 was isolative to self, aggressive, and irritable. He refused snacks and medications, and swung at staff when snacks or medications were offered. Review of progress note dated 01/07/26 at 3:27 PM revealed Patient #4 was confused and refused meals all day. Review of progress note dated 01/09/26 at 2:23 A.M. revealed Patient #4 refused food and medications and drank 90-120 milliliters of water. During an interview on 07/15/26 at 8:28 A.M. revealed the Director of Nursing (DON) D verified Patient #4 had no documentation for change in patient status related to skipping meals or poor intake. DON D confirmed Patient #4 was described as alert and oriented to self only, it was an inappropriate intervention to educate the patient regarding the importance of eating due to his cognitive status, and family should have been notified. Review of policy titled “Change in Patient Condition” dated 07/01/26 revealed nurses documented changes in condition, including assessments, findings, physician notifications, interventions, and patient/family communication, when a patient’s food or water intake reduced by 50% in a 24-hour period.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 42492 Based on review of the medical record, interviews, and policy review, the facility failed to ensure nursing staff documented daily intakes of food, beverages, and snacks, to monitor patients’ nutrition status. This affected eleven (Patient #3, #4, #5,#6, #9, #10, #11, #12, #13, #14, and #15) of fifteen patients sampled for nutrition. The facility census was 54. Findings include: 1. Review of the medical record revealed Patient #3 was involuntarily admitted on 05/14/25 with diagnoses including schizoaffective disorder bipolar type, cannabis abuse, chronic sinusitis, cocaine abuse, and essential hypertension. Patient #3 was discharged on 05/29/25. Review of the medical record revealed Patient #3 had no documentation in the medical record for the percentage of meals or beverages consumed on 05/18/25, 05/21/25, 05/22/25, 05/23/25, or 05/25/25. 2. Review of the medical record revealed Patient #4 was involuntarily admitted to the hospital on 12/30/25 from a Skilled Nursing Facility (SNF) with an admitting diagnosis of major depressive disorder. He was discharged back to his former SNF per family request on 01/09/26. Review of the medical record revealed Patient #4 had no documentation in the medical record for the percentage of meals or beverages consumed on 01/02/26, 01/03/26, 01/05/26, 01/07/26, and 01/08/26. 3. Review of the medical record revealed Patient #5 was involuntarily admitted to the hospital on 06/29/26 with a diagnosis of bipolar disorder with acute psychosis and mania related to insomnia. Patient #5 was discharged home with family on 07/13/26. Review of the medical record revealed Patient #5 had no documentation in the medical record for the percentage of meals or beverages consumed on 07/03/26, 07/07/26, 07/11/26, and 07/12/26. 4. Review of the medical record revealed Patient #6 was involuntarily admitted to the hospital on 07/02/26 with a diagnoses including bipolar disorder, autism spectrum disorder, ADHD, and cannabis use disorder. He was discharged home with family on 07/06/26. Review of the medical record revealed Patient #6 had no documentation in the medical record for the percentage of meals or beverages consumed on 07/04/26. 5. Review of the medical record revealed Patient #9 was involuntarily admitted to the hospital on 07/15/25 from a SNF and was discharged back to the SNF on 08/01/25. Review of the medical record revealed Patient #9 had no documentation in the medical record for the percentage of meals or beverages consumed on 07/27/25. 6. Review of the medial record revealed Patient #10 was admitted to the hospital on 02/16/25 for suicidal ideation with a diagnosis of bipolar disorder, severe with psychotic features, and with both auditory and visual hallucinations. Patient #10 was discharged on 02/19/25 to a medical facility. Review of the medical record revealed Patient #10 had no documentation in the medical record for the percentage of meals or beverages consumed on 02/17/25. 7. Review of the medical record revealed Patient #11 was involuntarily admitted to the hospital on 02/02/25 with a diagnosis of bipolar disorder, mixed episode. She had suicidal ideation with a plan to shoot herself with a gun or to cut her leg with a knife. She was discharged home on 02/09/25. Review of the medical record revealed Patient #11 had no documentation in the medical record for the percentage of meals or beverages consumed on 02/03/26 and 02/07/26. 8. Review of the medical record revealed Patient #12 admitted to the hospital on 02/01/26 with a diagnosis of bipolar disorder with psychosis for worsening depression and suicidal ideation. He was discharged home on 02/09/26 with recommendations for outpatient treatment. Review of the medical record revealed Patient #12 had no documentation in the medical record for the percentage of meals or beverages consumed on 02/02/26 and 02/03/26. 9. Review of the medical record revealed Patient #13 was admitted to the hospital on 01/23/26 for severe, recurrent major depressive disorder with psychosis and was discharged home with family on 02/04/26. Review of the medical record revealed Patient #13 had no documentation in the medical record for the percentage of meals or beverages consumed on 02/02/26, and 02/04/26. 10. Review of the medical record revealed Patient #14 was involuntarily admitted to the hospital on 07/08/26 for suicidal ideation with a diagnosis of schizoaffective disorder depressive type. Review of the medical record revealed Patient #14 had no documentation in the medical record for the percentage of meals or beverages consumed on 07/09/26, 07/11/26, 07/12/26, 07/13/26, and 07/14/26. 11. Review of the medical record revealed Patient #15 was voluntarily admitted to the hospital on 07/11/26 with a diagnosis of recurrent, sever major depressive disorder without psychosis. Review of the medical record revealed Patient #15 had no documentation in the medical record for the percentage of meals or beverages consumed on 07/13/26 and 07/14/26. During an interview on 07/15/26 at 8:37 A.M. the Director of Nursing (DON) D confirmed nursing staff did not appropriately document meal intakes or acceptance/refusals of snacks in Patient #4’s medical record. DON D stated staff were expected to document the percentage of food and beverages consumed at each meal and to document whether or not a patient accepted or refused snacks. During an interview on 07/16/26 at 9:20 A.M. Executive Director of Operations A and DON D verified nursing staff did not appropriately document meal intakes or acceptance/refusals of snacks in multiple medical records including Patients #3, #4, #5,#6, #9, #10, #11, #12, #13, #14, and #15. Review of policy titled “Nutrition Services,” dated 07/01/26 revealed staff monitored meals and documented meal, beverage, and snack intakes in the “Meal Acceptance” flowsheet in the medical record.”