Geisinger Behavioral Health Center Danville

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48679 Based on the systemic and serious nature of the standard level deficiencies related to nursing services, the facility staff failed to substantially comply with this Condition. The findings were: 482.23(b)(3) Tag 0395 The information reviewed during the survey provided evidence that the facility failed to document and escalate to the providers refusals of care and adequately reassess the patient which resulted in an adverse outcome (undetected cardiac and respiratory arrest) in 1 (one) of sixteen medical records reviewed. (MR1) 482.23(b)(5) Tag 0397 The information reviewed during the survey provided evidence that the facility failed to meet the needs of the patient as evidenced by failure to ensure observation checks performed were close enough to confirm the patient was breathing and not in distress as evidenced by staff remaining visibly in the hallway during 14 of 29 observations reviewed;and observation checks were insufficient length of time to observe for distress: staff observations lasted less than 10 seconds in 15 of 29 observations reviewed which resulted in an adverse outcome (undetected cardiac/ respiratory arrest) in one of one patient reviewed. (MR1) Cross reference 482.23(b)(3) 482.23(b)(5)”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 18754 Based on review of facility documents, medical record (MR) and staff (EMP) interview, it was determined the facility failed to log a received grievance, provide initial contact to the complainant, document efforts to achieve resolution and closure for one of six complaint/grievances reviewed (OTH1). Findings include: A review of facility policy “Grievances, Patient,” last revised by the facility in August 2025, revealed: “POLICY The Hospital will provide an effective mechanism for handling Persons Receiving Services (PRS)/family grievances as an important part of providing quality care and service to our PRSs. All PRSs and their families should have access to a clear process by which they may be heard if they believe their rights or other privileges have not been respected or responded to appropriately by facility or medical staff. ... The Governing Board has appointed the PRS Advocate the responsibility to execute the grievance program, in conjunction with the Grievance Committee. The Governing Board has established the membership of the Grievance Committee to include the Chief Executive Officer, Medical Director, PRS Advocate, Chief Nursing Officer, Director of Risk Management/Performance Improvement, Director of Clinical Services, and the Human Resource Director. ... If the PRS Advocate, CEO or Medical Director determines that resolution of the grievance requires additional review and input into the resolution process, or if the PRS is not satisfied with the actions taken to resolve the grievance, the Grievance Committee will be convened. ... DEFINITION... All verbal or written complaints regarding ... hospital compliance with CMS requirements are considered grievances for the purposes of these requirements. PROCEDURE 1. Staff present who receive a grievance/concern from a PRS/PRS’s legal representative will take the following steps: a. Acknowledge receipt of the grievance/concern by documenting the time and date of the grievance on the PRS Concern Notification form. b. Attempt to resolve the issue at the time of receipt. c. Document actions taken on the PRS Notification form. d. Forward PRS Concern Notification form to the PRS Advocate. ... 2. The PRS Advocate/ designee: a. Will record the concern/grievance on the designated tracking tool. b. Summarize the unresolved concerns on the Grievance Process Tool. c. Immediately review and assess any reported abuse/neglect. 3. The PRS Advocate or CEO/designee will review the grievance and complete the following: a. Assign follow-up to appropriate Director/Manager. Appropriate is defined as Director/Manager not connected to the grievance through supervision of the staff or responsibility for the process involved. b. Based on the investigation, a decision will be rendered in writing within 48 hours after the filing of the complaint. c. The PRS will be given a copy of the complaint and final decision, and a copy will be filed in the PRS’s record. 4. The Director/Manager to whom follow-up assigned will investigate the grievance, including but not limited to: a. PRS interview. b. Witness interview. c. Staff interview. d. Chart review e. Communication with other directors/managers. f. Record findings of investigation on the Grievance Process Tool and return to the PRS Advocate. 5. The PRS Advocate will: a. Review results of the preliminatry investigation b. Determine action to be taken. c. Involve CEO and Directors/Managers as necessary to achieve resolution. d. Complete a written report on the Grievance Resolution Form. Report to the PRS should contain the name of the hospital contact person, steps taken on behalf of the PRS to investigate the grievance and date of completion. ... f. Mail a written report if the complainant is not the PRS or the PRS has been discharged. g. Keep a copy of the report and document resolution on the Grievance Log. 6. The PRS Advocate will maintain all completed grievance reports ... 7. Any PRS, family, or guardian can appeal the grievance decision within 10 working days of the decision. a. The decision will be reviewed by the full Grievance Committee and render a decision within 10 working days. ... c. Minutes will be taken of the proceeding. d. A copy of the decisions will be given to the PRS, the CEO and filed in the PRS’s chart.” A review on August 26, 2026, of the complaint/grievance log, did not contain an entry of a complaint/grievance from the family of OTH1. Further review noted the last entry on the complaint/grievance tracking log was in mid July 2026. Interview with EMP4 on August 26, 2026, at approximately 1320, confirmed this was the most updated complaint/grievance tracking log. Interview conducted with EMP5 on August 26, 2026, at 1405 indicated that EMP5 spoke by telephone with the family member of patient of MR1 after August 20, 2026, and the family was upset they did not get notified by the facility of the patient’s (of MR1) death. Email communication with EMP1 on August 28, 2026, confirmed the facility did not list the family of OTH1’s concern as a complaint/grievance.”

“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: 48679 Based on review of facility policy, facility documents, medical records (MR) and staff (EMP) interview, it was determined the facility failed to document and escalate to the providers refusals of care and adequately reassess the patient which resulted in an adverse outcome (undetected cardiac and respiratory arrest) in 1 (one) of sixteen medical records reviewed. (MR1) Review on August 26, 2026, of facility policy “Vital Signs and Weights, last revised August 2025” revealed “Policy Vital Signs will be taken at the time of admission, as ordered by the practitioner and no less frequently than daily. PROCEDURE 1. Vital signs will be taken at the time of admission, as ordered by the practitioner and as patient’s condition warrants ... 3. All vital signs will be documented in the medical record by the assigned staff member...” Review on August 26, 2026, of facility policy “Change in Condition”, last revised August 2025” revealed “Policy The process for recognizing and responding as soon as a patient’s condition appears to be worsening shall be established. Staff shall contact the practitioner based on the established criteria. PROCEDURE Registered Nurse will provide assessment data to the physician/covering practitioner who will then give orders for treatment or additional assessment...22. Any concerns regarding the patient’s medical condition where nursing staff believes a delay may cause a negative outcome.” Review on August 26, 2026, of facility policy “Documentation Protocol, IM-009, effective May 2026” revealed “Policy: Facility records, reports, charts and documents are to be accurate, truthful, timely and complete ...PROCEDURE 5. Effective Documentation: Avoid vague observations, decisions and processes. Describe what you observe, not your opinion ... “ Review on August 27, 2026, of facility “Behavioral Health Associate I job description” revealed “PURPOSE STATEMENT: Responsible for providing personal care services to patients at the facility under the direction of clinical or nursing leadership. Demonstrate a positive, empathetic and professional attitude towards customers always. When patient needs are not met, acknowledge and work to resolve complaints. Recognize that patient safety is a top priority. ESSENTIAL FUNCTIONS: Demonstrate a sense of urgency related to the importance of patient safety and provide excellent customer service. Ensure the well-being of patients and provide a positive, supportive and structured environment. Responsible for conducting safety checks and ensuring that supervision is conducted at 15 minute intervals, as noted in special precautions, or in accordance with individualize supervision guidelines as needed. Document timely, accurate and appropriate clinical information in patient’s medical record. Assist in providing a safe, secure and comfortable environment for patients, significant others and staff. Interact routinely with patients, observe behaviors and communicate significant observations to nursing staff. May oversee or assist patient with activities of daily living, including toileting, bathing, dressing, grooming, oral hygiene, meals, snacks, hydration and changing bed linens. May obtain patient’s vital signs, height and weight as assigned and document in patient record... Complete and maintain required documentation. Assist with follow-up and paperwork as required on incidents and events that may take place in the facility...Recognize that patient safety is a top priority...” Review on August 27, 2026, of facility “LPN-LVN job description” revealed “PURPOSE STATEMENT: Providing nursing care and services within the standards and scope of nursing practice, as defined within the state Nurse Practice Act regulations, policies, procedures and protocols, as well as facility and corporate policies and procedures. Demonstrate a positive, empathetic, and professional attitude toward customers at all times. Recognize that patient safety is a top priority. ESSENTIAL FUNCTIONS: ... Collaborate with others to ensure that patients’ physical, biopsychosocial, age, developmental and cultural needs are met ...Provide for the basic comfort of patient, implement nursing interventions identified in the plan of care that is individualized to their needs...Discuss the care provided with patient and listen to their concerns. Report status changes and concerns to registered nurses and doctors...Provide for the safe delivery of medication in accordance with policies and procedures, physician orders and/or current practice...Responsible for thorough, accurate reporting and documentation of the patient symptoms, responses and progress...” Review on August 27, 2026, of facility “RN job description” revealed “PURPOSE STATEMENT: Responsible for providing professional nursing care to patients with a positive, empathetic, and professional attitude to foster a supportive and therapeutic environment. Recognize that patient safety is a top priority. ESSENTIAL FUNCTIONS: Provide and coordinate care by assessing physical and behavioral health needs of patient, develop and implement nursing care plans, maintain medical records...Ensure patient’s status is assessed on an ongoing basis and pertinent information gathered is documented...Notify physician of significant changes in status such as difficulties with detox, medical emergency or change in medical status regarding response to medications, etc...Accurately administer medications per ordered note...” Review on August 27, 2026, of facility “Chief Nursing Officer job description” revealed “PURPOSE STATEMENT: Responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing, other departments and the delivery of behavioral health/nursing services...ESSENTIAL FUNCTIONS: ... Ensure nursing services are provided in compliance with the laws and regulations of federal ... governmental agencies. Standards are met for accrediting agencies ...Oversee nursing services documentation to ensure it meets all standards.” Review of facility documents on August 26, 2026, revealed Endeavor Schedule 6:00am-7:20am Wake-up/Vital Signs/Morning hygiene/Med pass. 700am-7:40am Breakfast, 7:40am-8:00am Transition/Med Pass, 8:00am-9:00am Hygiene/Phone Time, 9:00am-10:00am Community Meeting: Goals Group. ... Review of MR1 on August 26, 2026, at approximately 1030 revealed physicians orders for vital signs routine daily. Vital signs were obtained on August 19, 2026 at 1429. There were no documented vital signs for August 20, 2026. Review on August 26, 2026, of facility documents dated August 21, 2026, regarding MR1 revealed EMP28 reported going to MR1s room with a trainee. EMP28 called for MR1 twice but there was no answer. EMP28 reported MR1s cheeks were puffing in and out and there was a faint snoring. EMP28 reported this was around 0730. EMP28 reported the vital sign list included two patients that were recommended to allow to sleep and MR1 was one of them. EMP28 reported MR1s vital signs were not obtained. EMP28 reported noticing the room smelled really bad of [a description of] bowel movement and thought someone [description of] used the toilet. EMP28 reported there was not a thought of MR1 being incontinent in bed and did not notice incontinence. Interview with EMP2 on August 26, 2026, at 1341 revealed daily vital signs are obtained at approximately 0600 am unless a patient is on a blood pressure (BP) medication. If a patient is on a BP medication, then vital signs are obtained at about 0800 am before their medications are given. EMP2 confirmed MR1s vital signs were not taken on August 20, 2026. Review of MR1 on August 26, 2026, revealed physicians orders for phlebotomy on August 19, 2026, which were scheduled to be obtained the morning of August 20, 2026. Review on August 26, 2026, of facility documents dated August 21, 2026, regarding MR1 revealed EMP29 reported being instructed by EMP18 not to obtain vitals on MR1 if sleeping. EMP29 reported on rounds hearing light snoring of MR1. EMP29 reported EMP31 arrived around 0515, announced self but MR1 wouldn’t wake up. EMP29 reported calling MR1s name several times, shook MR1 and MR1 did not wake and no response. EMP29 reported the phlebotomy was not completed because MR1 would not wake up. EMP29 reported seeing EMP31 speaking to the nurse and believed EMP31 was telling the nurse of the refusal. EMP29 did not document the interaction, or the blood work refusal and reported bloodwork refusals are not routinely documented. Interview with EMP6 on August 26, 2026, at 1438 confirmed there was one set of vital signs due August 20, 2026, between 0600-0720 (per Endeavor schedule) and a refusal of labs that were ordered for the morning of August 20, 2026, for MR1. EMP6 confirmed MR1 was not awoken for vital signs or phlebotomy. Review on August 26, 2026, of facility documents dated August 24, 2026, regarding MR1 revealed EMP31 reported arriving to the unit (Endeavor) around 0540 and was out of the unit by 0600. EMP31 reported trying to wake MR1, along with EMP29. EMP31 reported standing in between the two beds and EMP29 called MR1s name twice and pushed on MR1s shoulder with no response. Reported MR1 appeared to be sleeping and seemed to have wet the bed because it smelled like urine and there was drool on MR1s pillow. MR1 appeared to be sleeping, laying on side with arm under the pillow. EMP31 reported breathing was not checked. EMP31 reported EMP29 decided MR1 was not waking up and said to mark MR1 as a refusal. EMP31 reported notification of the refusal was not made because the nursing staff (EMP29) was present and the nursing staff was who would be notified. Reported MR1 seemed like someone in a deep sleep. Review of MR1 on August 26, 2026, revealed documentation was present from EMP18 on August 20, 2026, at 0609 which reported MR1 refused AM blood draw. No documentation was present that this was escalated to the provider. Interview with EMP2 on August 26, 2026, at 1341, confirmed the findings of EMP18 documenting in MR1 “Refused AM blood draw” and no other details were provided by EMP18 of refusal. Review on August 26, 2026, of facility documents dated August 22, 2026, regarding MR1 revealed EMP18 reported MR1 was snoring all through the night and morning, and around 0700 while final rounds were completed. EMP18 reported patients usually go to the cafeteria around 0645 but MR1 was sleeping and since MR1 was a new admission, the team made the decision to let MR1 sleep. Review on August 26, 2026, of facility documents dated August 21, 2026, regarding MR1 revealed EMP19, RN arrived at 0735 and patients were back from breakfast. EMP19 had no contact with MR1. EMP19 noted that rounds were completed and was told that MR1 was sleeping and didn’t want to eat breakfast so staff got a tray for MR1. Review on August 26, 2026, of facility documents dated August 21, 2026, regarding MR1 revealed EMP20 reported MR1 was due for medications at 0900 and told the behavioral health associate (BHA) if MR1 is sleeping, EMP20 would get the vitals at the time of medication administration. EMP20 reported realizing MR1 hadn’t gone for breakfast and asked the BHA to bring a tray back. EMP20 reported when it was about 1000, it was known that medication administration was approaching an hour over grace period. Upon entering the room EMP20 called MR1s name and there was no answer. Upon touching MR1s leg it felt very cold and EMP20 looked up and realized MR1 wasn’t right. EMP20 called for help and a code blue was called. Review of video footage on August 27, 2026, at 0957 with EMP14, EMP15 (for partial review), and EMP11(for partial review). A focused review was conducted on timeframes where specific care was supposed to occur such as medication administration, vital signs, meals, and phlebotomy was performed. On August 20, 2026, at approximately 5:53 AM, EMP29 and EMP31 enter the room with a phlebotomy supply cart and left the room at 5:54 AM. Video footage also reflected that from 0700- 0740, the patient did not leave the room for breakfast. There were no licensed nursing staff that entered the room with a medication cup for medication pass between 0740 - 0800 and the patient had not ambulated to the nursing station. EMP28 and EMP34 were noted to wheel the vital signs machine to the patient’s room and EMP28 enters room 407 at 7:38 AM and then again at 7:39 AM and both times the vital signs machine was left outside the room with EMP34 near the machine. Review on August 26, 2026, of facility documents dated August 22, 2026, regarding MR1 revealed EMP30 reported there was an odor prior to the Code Blue for MR1 and it could be smelled in the hallway. Review of MR1 on August 26, 2026, revealed no documentation was present MR1 missed or refused vital signs. No documentation was present in MR1 that breakfast was missed or refused. There was no documentation of MR1 being incontinent or of an odor in room. Interview with EMP6 on August 26, 2026, at 1438 regarding above findings. EMP6 stated there obviously wasn’t something done correctly. EMP6 stated that staff should be documenting refusals of vital signs, labs, meds, weights. They all need charted as such and documented. EMP6 related the escalation process should be from the behavioral health associate (BHA) to the nurse, nurse to physician and to document the communication. EMP6 stated it was questionable whether the patient refused versus just didn’t awake. Interview with EMP2 on August 27, 2026, at approximately 1130 confirmed there was no documentation of incontinence care in MR1 and stated if a patient has incontinence the behavioral health associate should assist with incontinence care as per their job description A request was made of EMP1 on August 27, 2026, at 1455 for a facility policy/protocol/guideline specific to criteria the behavioral health associate shall escalate and report to nursing staff. None was provided. Interview with EMP1 and EMP2 on August 27, 2026, at 1415 revealed the facility does not have a policy specific to patient refusals. Interview with EMP16 on August 27, 2026, at 1504 related routine meds are usually administered between 1600- 1700, 1900, and 0800- 0900. EMP16 confirmed in review of MR1, there were no medications given to the patient in the morning of August 20, 2026. EMP16 related that sometimes they may wait to obtain vital signs until closer to the med pass, especially when a patient is on antihypertensive medications, then the nurse may prefer to get the blood pressure (BP). Review of MR1 on August 26, 2026, revealed the following Code Blue documentation. Documentation revealed a code blue was called on August 20, 2026, at 1010. EMP5, MD, presented at 1010. 911 was called at 1011. Chest compressions were started at 1012 and continued until 1024. EMS arrived at 1024 and took over medical control. CPR was stopped at 1024 and MR1 was pronounced dead. Interview with EMP5 on August 26, 2026, at 1405 confirmed findings. EMP5 stated when they arrived to patient’s room, CPR was in progress, the defibrillator was out, and staff were taking turns doing compressions. EMP5 stated the patient’s (of MR1) body was blue, legs were cold to touch. EMP5 related patient never had a pulse or respirations. EMP5 stated EMS came and took over the CPR for approximately 10-15 minutes then stopped. Cross reference 482.23(b)(3) 482.23(b)(5)”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 18754 Based on review of facility policy, medical record (MR) review, observations, and staff (EMP) interview, it was determined the facility failed to meet the needs of the patient as evidenced by failure to ensure observation checks performed were close enough to confirm the patient was breathing and not in distress by staff remaining visibly in the hallway during 14 of 29 observations reviewed; and observation checks were of insufficient length of time to observe for distress (staff observations lasted less than 10 seconds) in 15 of 29 observations reviewed which resulted in an adverse outcome (undetected cardiac/ respiratory arrest which resulted in death) in one of one patient (MR1). Review of facility policy “Video Surveillance & Recording,” last revised by facility in January 2022, revealed “Video Surveillance & Recording... 2. PURPOSE: To establish guidelines related to the use of video monitoring and recording of patients and staff in order to evaluate and maintain a safe and therapeutic treatment environment. Use of video surveillance system may also: ... assist in the application and enforcement of policies ... 4. PROCEDURE: Location of Monitors: Video monitoring may (but is not requred to) be used continuously in patient care areas to monitor both patient and staff safety. Areas in wehich video monitoring may occur include, but are not limited to: ... hallways ... Notifications/Consent: Signed acknowledgement of the use of camera and surveillance equipment is obtained for the paitent or their legal guardians on admission. Upon hire, employees sign an acknowledgement of camara use within and around the facility. Signage is placed on the front door of the facility’s main entrance as well as the patient care areas. ... “ Review of facility policy “Observations, Patient,” last revised April 2026, revealed: “POLICY In order to maintain patient safety, the hospital staff makes and documents routine safety rounding on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. ... PROCEDURE 1. The psychiatric practitioner will order on of three levels of observation at time of admission and as the patient’s condition warrants a change: a. 15 minute b. 5 minute c. One-to-one ... 6. Documentation of Observations a. Proximity-Based Electronic Technology i. Staff documents all levels of observation on each patient’s profile on the facility issued device using proximity-based electronic technology. The observation report is then printed and becomes a part of the patient record at discharge. Each entry is to include the following: Location Behavior/Activity Time is recorded electronically when the entry is made Signatures are completed electronically by the assigned staff using their unique login to the system.... iii. Documentation of the observation is to be completed once the patient has been observed. ... b. Paper Documentation including Downtime of an EMR “ [electronic medical record] “ i. Staff documents all levels of observation on each patient’s observation form which becomes a part of the patient record. ... 7. Q” [every] “15 Minute Observations i. All patients are monitored at minimum once in every 15 minute block of time. ii. In order to minimize the chance that patients may anticipate the timing of the observations; the staff are instructed to vary the order in which patients are observed within each 15 minute period. iii. During the observations staff are to: i. Make direct visual contact; look for signs of danger or distress, even if the patient is in the bathroom ii. Observe sleeping patients close enough to confirm they are breathing and not in any physical distress such as bleeding, lying on the floor, very restless, etc. ... Charge RN/RN Designee ... d. Each RN is responsible for general oversight of the safety observation on his/her assigned patients ...Monitoring 1. Monitoring for compliance with Observations will be a continuous, ongoing process. ... “ Review of MR1 on August 26, 2026, at 1000 revealed patient of MR1’s physician ordered observation level was every 15 minutes. Interview with EMP3 on August 26, 2026, at approximately 1103 stated that with observation checks the practice is for staff to look for three (3) rise/falls of the chest and that the patient is not in distress. Surveyor asked EMP3 whether the 3 rise and falls of the chest was something new, and EMP3 responded no, it’s always been their practice. During tour and observations with EMP3 on August 26, 2026, at approximately 1103, the surveyor observed that the staff use [name of System] which is an electronic documentation of observations system. The patient wears a band on the wrist or ankle and when the staff’s iPad comes into proximity with the patient (within approximately 10 feet), the iPad shows the patient’s name and staff clicks on the name and enters additional information to the documentation (i.e. location/behavior observed). At the time of tour, there was not an issue with this specific observation. Interview with EMP2 on August 26, 2026, at approximately 1145 indicated that the patient of MR1 was located by the window of the double occupancy room. Further interview with EMP2 stated the practice for observations checks was for staff to watch for at least 3 rise/falls of the chest and ensure the patient was not in distress by visualizing their face. Review of video footage on August 27, 2026, at 0957 with EMP 14, EMP15 (for partial review) and EMP11 (for partial review). The focused timeframe of the video footage reviewed was dated on August 20, 2026, from 6:00 A.M. to 11:19 A.M. EMP15 confirmed which room the patient of MR1 had been located in. The video footage is only of the hallway; there is no video footage within patient rooms. During the following observation checks the staff’s body remained visibly in the doorway at the following date/times stamped on the video (Times are in hour: minute: second format): August 20, 2026, at 7:07:47 A.M., August 20, 2026, at 7:14:56 A.M., August 20, 2026, at 7:53:24 A.M., August 20, 2026, at 7:57:17 A.M., August 20, 2026, at 8:06:41 A.M., August 20, 2026, at 8:08:08 A.M., August 20, 2026, at 8:19:43 A.M., August 20, 2026, at 8:47:54 A.M., August 20, 2026, at 9:10:48 A.M., August 20, 2026, at 9:22:55 A.M., August 20, 2026, at 9:33:28 A.M., August 20, 2026, at 9:45:44 A.M., August 20, 2026, at 9:57:56 A.M., and August, 20, 2026, at 10:06:52 A.M. Further review of video footage on August 27, 2026, at 0957 with EMP 14, EMP15 (for partial review) and EMP11 (for partial review showed observation safety checks were insufficient length of time to adequately observe for distress (observe for 3 rise/falls of the chest per stated expectation/practice). The following date/times stamps according to the video footage were less than 10 seconds in length: August 20, 2026, at 6:26:47 A.M. - 6:26:55 A.M (8 seconds), August 20, 2026, at 6:36:41 A.M.- 6:26:48 A.M. (7 seconds), August 20, 2026, at 7:07:47 A.M.- 7:07:51 A.M. (4 seconds), August 20, 2026, at 7:14:56- 7:14:59 A.M. (3 seconds), August 20, 2026, at 7:27:55 A.M.- 7:28:01 A.M. (6 seconds), August 20, 2026, at 7:41:45 A.M.- 7:41:51 A.M. (6 seconds), August 20, 2026, at 7:57:17 A.M- 7:57:19 A.M. (2 seconds), August 20, 2026, at 8:06:41 A.M.- 8:06:49 A.M. (8 seconds), August 20, 2026, at 8:08:05 A.M.- 8:08:08 A.M. (3 seconds), August 20, 2026, at 8:19:43 A.M.- 8:19:48 A.M.(5 seconds), August 20, 2026, at 8:47:54 A.M.- 8:48:01 A.M. (7 seconds), August 20, 2026, at 9:01:04 A.M.- 9:01:10 A.M. (6 seconds), August 20, 2026, at 9:22:55 A.M.- 9:23:01 A.M. (6 seconds), August 20, 2026, at 9:33:28 A.M.- 9:33:33 A.M. (5 seconds), and August 20, 2026, at 9:45:44 A.M.- 9:45:53 A.M. (7 seconds). Further review of video footage dated August 20, 2026, at 10:16:15 A.M. shows staff entering room of patient of MR1, then at 10:16:30 the same staff jogging toward the nursing station, pointing toward the nursing station and then returning to room of patient of MR1, and at 10:18:02 shows additional staff entry to room of patient of MR1 with the crash cart. EMS arrives on scene at 10:26:00 AM. Police arrive approximately 10:35: 18. At 10:36:27 all EMS staff leave patient room. At 10:46:35 AM the coroner arrives and at 11:19:23 AM the coroner exits with the patient of MR1. Interview with EMP2 on August 26, 2026, at approximately 1145 indicated that the patient of MR1 was located by the window of the double occupancy room facing the window when found unresponsive and in cardiac/respiratory arrest. Further interview with EMP2 stated the practice for observations checks was for staff to watch for at least 3 rise/falls of the chest and ensure the patient was not in distress by visualizing their face. Interview with EMP1 on August 27, 2026, at 1710 and discussed that the video times in comparison to the observation safety checks did not match. EMP1 confirmed via telephone call with EMP15 that there was a lag on the timestamp of the video. Cross reference 482.23(b)(3) 482.23(b)(5)”