Lakeside Behavioral Health System

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49575 Based on hospital policy review, documentation review, medical record review, video surveillance review, and interview, the hospital failed to protect and promote each patient ’ s right to receive care in a safe setting and be free from abuse and neglect; and failed to report patient to patient abuse, investigate the abuse and implement corrective action plans to prevent further abuse. The findings included: 1.The hospital failed to ensure patients received care in a safe setting through appropriate patient supervision and monitoring practices to prevent abuse. Review of the hospital ’ s video surveillance of the Behavioral Unit revealed Patient #2 exited her room and wandered the hallway. There was no observation that the Mental Health Technicians.who was assigned to monitor the hallway, attempted to redirect Patient #1. Review of hospital documentation revealed Patient #2 had entered Patient #1 ’ s room and assaulted Patient #1 while the patient was sleeping breaking the patient ’ s nose. During an interview, on 4/28/2026 at 9:00 AM, Director of Nursing (DON) #3 stated on the morning of 4/18/2026, she received a text from the Charge Nurse that stated Patient #1 had a broken nose. The DON#3 stated Patient #1 was not sent out for further treatment. During an interview, on 4/28/2026, at 10:49 AM, the Charge Nurse stated that he worked the 7:00 PM - 7:00 AM shift on 4/17/2026. The Charge Nurse stated that during the shift, he had been informed that Patient #2 had struck Patient #1 in the face while Patient #1 was in bed. The Charge Nurse also stated that Patient #1 was upset and he contacted and reported the incident to the on-call Advanced Practice Registered Nurse (APRN). The Charge Nurse said the APRN did not come to the hospital to assess either patient. Patient #1 and Patient #2 returned to bed without incident. Neither patient needed further/off-site intervention. Refer to A-0144 1.The hospital failed to ensure incidents involving potential abuse and/or neglect were immediately investigated and reported to ensure ongoing patient protection and prevent the potential for additional harm. Review of hospital ’ s document, Medical Send Outs, dated 3/1/2026 - 4/28/2026 revealed there was no documentation of a complete and thorough investigation into the patient to patient abuse incident when Patient #2 attacked Patient #1 as she slept in her bed on 4/17/2026. The was no documentation a corrective action plan had been developed and implemented to prevent further patient abuse. During an interview, on 4/28/2026 at 10:00 AM, the Director of Regulatory and Quality (DRQ) stated that if a patient sustained a broken nose after being attacked at the hospital, the incident should be investigated and reported. The DRQ stated that she had not been made aware of the incident between Patient #1 and Patient #2 until now. Refer to A-0145”

“Special Staff Requirements CFR(s): Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This Condition is not met as evidenced by: 49575 Based on policy review, document review, video review and interview, the hospital failed to ensure it maintained an effective operational system to ensure patient safety and provide a safe environment during patients ’ hospitalization. The findings include: 1. Review of hospital policy, “Organization Plan for Patient Safety,” revised 3/2026, revealed, “...the purpose and goal of the facility ’ s Organizational Plan for the Patient Safety is to establish and maintain effective operational systems to prevent errors and assure the safe delivery of care and services...” ...” 2. Review of hospital policy, “Patient Observation Guidelines,” revised 1/2026, revealed, “...It is the policy of [named psychiatric hospital] to provide a safe and secure environment for patients during their hospitalization. All patients will be routinely observed in compliance with physician orders and prescribed protocols. 3. Review of Medical Record for Patient #2 revealed an admission date of 4/12/2026 with diagnoses which included Schizoaffective Disorder (a mental illness that affects how a person thinks, feels and behaves). Review of Medical Record for Patient #1 revealed an involuntary admission date of 4/15/2026 with diagnoses which included Gross Confusion, Psychosis (loss of contact with reality). Review of the hospital ’ s video recording revealed on 4/17/2026 Patient #2 was wandering the halls. There was no observation the Mental Health Technicians who were assigned to monitor the halls redirected Patient #2. At approximately 10:11 PM, Patient #2 entered Patient #1 ’ s room and and punched Patient #1 in the face while the patient was sleeping. Documentation revealed Patient #1 suffered a bloody nose, and an x-ray revealed Patient #1 had sustained a nasal fracture as a result of being punched in the face. Patient #1 was inpatient for a period of 13 days. There was no documentation the psychiatric hospital ’ s staff made observations of Patient #1 based on physician ’ s order for her level of observation or the level changed based on the changing needs of Patient #1. Patient #2 was inpatient for a period of 11 days. from 4/12/2026 - 4/23/2026. There was no documentation the psychiatric hospital ’ s staff made observations of Patient #2 based on physician ’ s order for her level of observation or the level changed based on the changing needs of Patient #2. Refer to A 1685”

“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: 49575 Based on hospital policy review, video surveillance review, medical record review, and interview, the hospital failed to ensure 1 of 5 (Patient #1) sampled patients received care in a safe setting in order to protect the patient ’ s emotional and physical health. The findings included: 1. Review of hospital policy, “Organization Plan for Patient Safety,” revised 3/2026, revealed, “...the purpose and goal of the facility ’ s Organizational Plan for the Patient Safety is to establish and maintain effective operational systems to prevent errors and assure the safe delivery of care and services ...Patients have the right to expect safe care and services ...Patients have the right to be informed about outcomes of care including undesired and unexpected occurrences ...” Review of hospital policy, “Patient Observation Guidelines,” revised 1/2026, revealed, “...while Mental Health Technicians [MHT] are monitoring hallways and patient care areas, they are to ensure that patients are not entering rooms not assigned to them...” 2. Medical Record review for Patient #1 revealed an involuntary admission date of 4/15/2026 at 6:25 AM with diagnoses which included Gross Confusion, Psychosis (loss of contact with reality), Agitation (severe restlessness, irritability, or mental distress), Delusions (fixed false belief despite clear evidence), and Positive Drug Screens for tetrahydrocannabinol ((THC)- the primary psychoactive substance in cannabis/marijuana, producing intoxicating effects, euphoria, and altered perception) and Fentanyl (a highly potent synthetic opioid used to treat pain). The record revealed the patient had increased aggression, delusional behavior, and sexually inappropriate behavior evidenced by walking naked in the street. Upon arrival to the unit, Patient #1 was alert to person only and was admitted to the East Behavioral Unit. Review of a Psychiatric Progress Note written 4/16/2026 at 7:00 AM revealed, “...[Patient #1 was] started on med, compliant w [with] po [oral; by mouth] meds so far... angry, paranoid, disorganized, disrobed w clothes broken like bra, FOI [flight of ideas]/blocking; received PRN [as needed medications] x2 [twice] yesterday- no SE [side effects] ...” Review of a Psychiatric Progress Note written 4/17/2026 at 7:00 AM revealed, “... episode of agitation/aggression [since] yesterday PM; Received PRN x 1 - IM [intramuscular - medication given in the muscle] Abilify [medication used to treat schizophrenia, bipolar disorder and major depressive disorder] last night; still manic, delusions, elated, disorganized, no sedation... Risperidol [medication to treat schizophrenia and bipolar disorder] to 2 mg [milligrams] BID [twice a day]...” Review of video surveillance footage of the East unit revealed Patient #2 exited her room on 4/17/2026 at 10:10 PM. At 10:11 PM, Patient #2 entered Patient #1 ’ s room. At 10:12 PM, two Mental Health Technicians stood up, walked to and entered Patient #1 ’ s room. Review of Master Treatment Plan Update/Clinical Staffing Worksheet dated 4/17/2026, revealed Patient #1 was “...attacked by peer [Patient #2] ...Nose broken...x-ray confirmed...” Review of Nasal Bones X-ray, dated 4/17/2026, revealed “...A small acute non-displaced fracture of the nasal bone...” There was no documentation a safety plan had been developed and implemented to prevent Patient #1 from being assaulted. Review of Psychiatric Progress Note, dated 4/18/2026 at 8:00 AM, revealed Patient #1 was “ ... still labile, impulsive [acting without consideration of consequences], needs frequent redirection, delusional [having a firm belief in something that is untrue] w/impaired attention. Wearing other pt ’ s [patient ’ s] clothes yesterday and was punched on face by the other pt [Patient #2] ...nose fracture ... + [add] Lithium [medication used to stabilize mood] for mood ...” Review of Psychiatric Progress Note dated 4/19/2026 at 9:30 AM revealed Patient #1 had, “... [symbol for decreased] agitation/aggression and mania [wild, reckless or violent behavior]; still impulsive, delusional, paranoid, severe impaired attentions. Needs redirection. Received PRN x 2 yesterday again. No sedation...” Review of Psychiatric Progress Note dated 4/20/2026 at 8:00 AM revealed Patient #1 was, “... anxious, [symbol for decreased] manic, ...limited impulse & [and] anger control. Received PRN x 1 last night not [illegible] her PO meds, [illegible]... [increased] Risperidol to 3 mg BID...” Review of the Hospital ’ s Medical Consultation dated 4/20/2026 revealed, “... xray review small non-displaced fracture of nasal bone Remaining visualized osseous structures are WNL [within normal limits] Normal facial bones - no acute injury; no intervention needed at this time. F/U [follow-up] c [with] ENT [Ear, Nose, Throat Specialist] ...” Review of Psychiatric Progress Note dated 4 /21/2026 at 7:00 AM revealed Patient #1 was, “... compliant w/ meds. No SE [side effects from medications]. Still limited coping skills. Impulsive... No PRN last night X1 in AM early...” Review of Psychiatric Progress Note dated 4/22/2026 at 7:00 AM revealed Patient #1 had “... [symbol for decreased] manic, [symbol for decreased] agitation; still impulsive - not following directions at times. Limited cooperation w/ tx [treatment]. No SI [suicidal ideations - thoughts of committing suicide]/HI [homicidal ideations - thoughts of killing others] ... [increased] Depakote [medication used to treat manic- depressive disorders] ...” Review of Psychiatric Progress Note dated 4/23/2026 at 8:00 AM revealed Patient #1 was, “...[illegible] impulsive ... [symbol for decreased] labile, [symbol for decreased] aggression, no SI/HI... no prn yesterday...” Review of Psychiatric Progress Note dated 4/24/2026 at 7:30 AM revealed, Patient #1, “... still limited coping skills... angry at times, [symbol for decreased] aggression... needs redirection...” Review of Psychiatric Progress Note dated 4/25/2026 at 11:00 AM revealed Patient #1 experienced, “... [symbol for decreased] labile, no anger/aggression; still limited coping skills; no SI/HI...” Review of Psychiatric Progress Note dated 4/26/2026 at 8:30 AM revealed Patient #1 was “... Doing better, [symbol for decreased] labile, [symbol for decreased] intense, [symbol for decreased] angry; still slow coping; no SI/HI, no SE...” Review of Psychiatric Progress Note dated 4/27/2026 at 8:00 AM revealed Patient #1 was “... Doing better, [symbol for decreased] labile ...No SI...No aggression, more coherent... Plan to D/C discharge] Home...” Review of the handwritten Physician Discharge Order Discharge Plan dated 4/28/2026 at 8:00 AM revealed, “... Psychiatric and Medical Diagnosis... schizoaffective disorder... MJ [abbreviation for marijuana] use disorder, mild...” Review of the Discharge Note for Adult Services dated 4/28/2026 at 12:20 PM revealed, “... Patient is alert, oriented x 4 (person, place, time and situation); stable; denies SI, HI and denies AH (auditory hallucinations) and VH (visual hallucinations) ... Pt reports feeling better, she says ’ I will stay on my meds and go to my appointments to continue to feel better ’ “ There was no documentation of the status of Patient #1 ’ s broken nose. 3. Review of Medical Record for Patient #2 revealed an admission date of 4/12/2026 with diagnoses which included Schizoaffective Disorder (a mental illness that affects how a person thinks, feels and behaves), Bipolar Disorder (mental illness characterized by increased irritable mood, increased energy, decreased need for sleep, rapid speech and risky behaviors, at times alternating with periods of depression), and Cannabis (marijuana) Use Disorder. Review of Progress Note dated 4/17/2026 at 10:15 PM, revealed “...Pt [Patient #2] punched peer [Patient #1] in face while peer [Patient #1] was asleep ...Peer [Patient #1] was wearing Pt ’ s [Patient #2 ’ s] clothes w/o [without] her [Patient #2] permission. Stat X-Ray and Neuro check ordered for Peer [Patient #1] ...” Review of the observation log dated 4/17/2026 revealed the following observations and behaviors were documented for Patient #2 from 9:52 PM to 10:09 PM. At 9:52 PM, Pt #2 was in the patio/yard and was calm; At 10:07 PM, Pt #2 was in the bedroom and appears sleeping on right; At 10:09 PM, Pt #2 was in the bedroom and appears sleeping on right. There was no documentation at 10:10 PM of Patient #2 walking the hallway and at 10:11 PM entering Patient #1 ’ s room assaulting Patient #1. There was no documentation a safety action plan was developed and implemented to prevent Patient #2 from assaulting other patients. Review of Psychiatric Progress Note for Patient #2 dated 4/18/2026 at 7:25 AM revealed, Patient #2 “...[was] labile, impulsive & unpredictable [with] + [positive] SI with thoughts of taking OD [overdose]...” Review of Psychiatric Progress Note for Patient #2, dated 4/19/2026 at 8:10 AM, revealed “Pt [Patient #2] was aggressive & [and] agitated yesterday AM [before lunch] ...Attacked and punched... [Patient #1] unprovoked ... [increase] Zyprexa to 5 mg to BID [twice a day]...” Review of Master Treatment Plan Update/Clinical Staffing Worksheet, dated 4/20/2026, for Patient #2 revealed, “...on 4/17/2026 Patient #2 assaulted [Patient #1] and broke peer ’ s [Patient #1] nose because she [Patient #1] was wearing her [Patient #2] clothes...” Review of the Discharge Summary for Patient #2 revealed a discharge dated of 4/23/2026. Patient #2 ’ s discharge diagnoses included Schizoaffective Disorder, Bipolar Type and Cannabis Use Disorder, Moderate with a long history of mental illness and multiple recent inpatient treatments, with the most recent inpatient treatment at this psychiatric hospital. The summary documented Patient #2 was hearing voices telling her to kill herself and others and was noncompliant with taking medications. The summary revealed during the patient ’ s hospital stay “... The patient [Patient #2] required p.r.n. medications because of increase in psychosis and agitation and the patient attacked [Patient #1] unprovoked, and she was put on one-to-one. She started doing better since then. Her one-to-one was discontinued. Now, the patient is stable...” At the time of discharge, the patient was calm and cooperative; mood stable; affect appropriate. The patient denied having any auditory, visual, or tactile hallucinations. The patient also denied any homicidal or suicidal thoughts. The discharge summary documented at the time of discharge, the patient was not a danger to herself or others and was stable. 4. During an interview on 4/28/2026 at 8:43 AM, Registered Nurse (RN) #8, stated it was reported that Patient #2 went into Patient #1 ’ s room and punched her in the nose while Patient #1 was sleeping. RN #8 stated she had not witnessed Patient #2 going into Patient #1 ’ s room. RN #8 stated the Charge Nurse had asked her to clean up Patient #1 ’ s bloody nose after the incident had occurred. RN #8 stated she placed a cool towel to Patient #1 ’ s face and nose. RN #8 stated there was no active bleeding at the time she placed the towel on her face and nose. During an interview, on 4/28/2026 at 9:00 AM, Director of Nursing (DON) #3 stated on the morning of 4/18/2026, she received a text from the Charge Nurse that stated Patient #1 had a broken nose. The DON#3 stated Patient #1 was not sent out for further treatment. During an interview, on 4/28/2026 at 9:43 AM, Mental Health Technician (MHT) #7 stated while performing patient rounds during the night shift on 4/17/2025, she heard Patient #2 fussing with Patient #1 about her clothes. MHT #7 stated she had already made rounds on Patient #1 and walked back to Patient #1 ’ s room when she heard the fussing. MHT #7 stated she found Patient #1 crying and Patient #2 demanding that Patient #1 return her clothes. During an interview on 4/28/2026 at 10:35 AM, MHT #8 stated Patient #2 went down the hall complaining her clothes that had been washed, were missing. Patient #2 was wandering around the hall and said if she did not find her clothes, she would do something to get in seclusion. Patient #2 then went to Patient #1 ’ s room. MHT #8 was not aware of Patient #1 or Patient #2 being on any increased precautions or observations. During an interview, on 4/28/2026, at 10:49 AM, the Charge Nurse stated he worked the 7:00 PM - 7:00 AM shift on 4/17/2026. The Charge Nurse stated, during the shift, he had been informed that Patient #2 had struck Patient #1 in the face while Patient #1 was in bed. The Charge Nurse stated Patient #1 was upset and he contacted and reported the incident to the on-call Advanced Practice Registered Nurse (APRN). The Charge Nurse said the APRN did not come to the hospital to assess either patient. Patient #1 and Patient #2 returned to bed without incident. Neither patient needed further/off-site intervention. During an interview on 4/28/2026 at 11:31 AM, MHT #9 stated she had been observing another patient on the East Unit on the night of 4/17/2026 when she heard Patient #2 yelling because she was looking for her clothes that were missing. MHT #9 stated Patient #2 had entered Patient #1 ’ s room and when Patient #1 exited the room, Patient #1 ’ s face was bleeding. During an interview on 4/30/2026 at 8:40 AM, MHT #10 stated she had worked the 7:00 PM - 7:00 AM shift on 4/17/2026 and had witnessed Patient #2 walking into random patient ’ s rooms looking for her clothes. MHT #10 stated she informed Patient #2 that she was not allowed to go into other patients ’ rooms. During an interview, on 4/30/2026 at 9:35 AM, MHT #1 stated she had worked the 7:00 PM - 7:00 AM shift on 4/17/2026. MHT #1 stated she and MHT #9 were performing patient rounds when they observed Patient #2 in the hallway talking to other patients. MHT #1 stated during the shift she observed Patient #2 walk into Patient #1 ’ s room and heard Patient #2 ask Patient #1 for her clothes. MHT #1 stated that ’ s when she and MHT #9 walked to Patient #1 ’ s room. MHT #1 stated she observed Patient #2 punch Patient #1 in the face. MHT #1stated she proceeded to remove Patient #2 from Patient #1 ’ s room. During an interview on 4/30/2026 at 11:52 AM, the APRN stated she was on call on 4/17/2026 but not on campus. She received a call from the Charge Nurse notifying her Patient #2 had punched Patient #1 in the nose while Patient #1 was sleeping in her bed. APRN stated the information she received was that it was a superficial injury, so she did not make the decision to send Patient #1 out for evaluation. There was no change in Patient #1 ’ s level of consciousness. APRN stated she ordered Patient #1 to be monitored and do neuro checks every 1 hour for the next 4 hours. (There was no documentation neuro checks were done every 1 hour for 4 hours as ordered by the APRN). She stated she was told Patient #1 had no residual injuries or concerns; medical was onsite; she (APRN) would follow-up and see the patient the following morning. The APRN stated no one called regarding any further concerns about the patient. There was documentation there were interventions developed and implemented of a safety paln to prevent this type of assault from happening again. There was no documentation Patient #1 was monitored more frequently after being assaulted in the face for any signs or symptoms of distress such as swelling, bleeding or breathing difficulties; and no documentation Patient #2 was monitored more frequently to prevent her from assaulting other peers (patients).”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 49575 Based on hospital policy review, hospital documentation, medical record review, and interview, the hospital failed to ensure a witnessed incident of abuse was reported in a timely fashion to administrative staff; failed to properly investigate a witnessed incident of abuse; and failed to develop and implement corrective actions to prevent further patient abuse for 1 of 5 (Patient #1) sampled patients reviewed. The findings included: 1. Review of hospital policy, “Incident Report-IR/Incident Reporting Process,” revised 1/2026, revealed, “The Incident Report-IR/Incident Reporting Process is ...used to track incidents, outcomes... patient safety concerns or questionable clinical practices. Any health care facility employee who discovers, is directly involved in, or responds to an incident is to complete or direct completion of an IR/Incident Report as soon after the event as possible, but not later than the end of the shift ... Appropriate notifications are completed, including the attending physician, CEO (Chief Executive Officer)/designee, parent/guardian, risk manager ...” 2. Review of Medical Record for Patient #1 revealed an involuntary admission date of 4/15/2026 with diagnoses which included Gross Confusion, Psychosis (loss of contact with reality), Agitation (severe restlessness, irritability, or mental distress), Delusions (fixed false belief despite clear evidence), and Positive Drug Screens for tetrahydrocannabinol ((THC)- the primary psychoactive substance in cannabis, producing intoxicating effects, euphoria, and altered perception] and Fentanyl (a highly potent synthetic opioid used to treat pain). Review of Master Treatment Plan Update/Clinical Staffing Worksheet dated 4/17/2026, revealed Patient #1 was “...attacked by peer [Patient #2] ...Nose broken...x-ray confirmed...” During an interview, on 4/30/2026 at 9:35 AM, MHT #1 stated she had worked the 7:00 PM - 7:00 AM shift on 4/17/2026. MHT #1 stated she and MHT #9 were performing patient rounds when they observed Patient #2 in the hallway talking to other patients. MHT #1 stated during the shift she observed Patient #2 walk into Patient #1 ’ s room and heard Patient #2 ask for Patient #1 for her clothes. MHT #1 stated that ’ s when she and MHT #9 walked to Patient #1 ’ s room. MHT #1 stated she observed Patient #2 punch Patient #1 in the face. MHT #1 stated she proceeded to remove Patient #2 from Patient #1 ’ s room. 3.Review of Medical Record for Patient #2 revealed an admission date of 4/12/2026 with diagnoses which included Schizoaffective Disorder (a mental illness that affects how a person thinks, feels and behaves), Bipolar Disorder (mental illness characterized by increased irritable mood, increased energy, decreased need for sleep, rapid speech and risky behaviors, at times alternating with periods of depression), and Cannabis (marijuana) Use Disorder. Review of Master Treatment Plan Update/Clinical Staffing Worksheet, dated 4/20/2026, for Patient #2 revealed, “...on 4/17/2026 Patient #2 assaulted [Patient #1] and broke peer ’ s [Patient #1] nose because she [Patient #1] was wearing her [Patient #2] clothes...” Review of hospital ’ s document, Medical Send Outs, dated 3/1/2026 - 4/28/2026 revealed there was no documentation of a complete and thorough investigation into the patient to patient abuse incident when Patient #2 attacked Patient #1 as she slept in her bed on 4/17/2026. The was no documentation a corrective action plan had been developed and implemented to prevent further peer (patient) abuse. 4. During an interview, on 4/28/2026 at 10:00 AM, the Director of Regulatory and Quality (DRQ) stated that if a patient sustained a broken nose after being attacked at the hospital, the incident should be investigated and reported. The DRQ stated she had not been made aware of the incident between Patient #1 and Patient #2 until now. During an interview, on 4/29/2026 at 2:15 PM, the Chief Nursing Officer stated the incident had not been appropriately reported and family of the patients involved had not been notified of the incident.”

“Personnel - Evaluate Patients CFR(s): Standard: Personnel The hospital must employ or undertake to provide adequate numbers of qualified professional, technical, and consultative personnel to: Evaluate Patients This Standard is not met as evidenced by: 49575 Based on policy review, document review and interview, the hospital failed to ensure the provision of a safe, secure environment during patients ’ hospitalization when 1 of 5 (Patient #1) sampled patients was attacked as she was sleeping. The findings included: 1. Review of hospital policy, “Organization Plan for Patient Safety,” revised 3/2026, revealed, “...the purpose and goal of the facility ’ s Organizational Plan for the Patient Safety is to establish and maintain effective operational systems to prevent errors and assure the safe delivery of care and services ...Patients have the right to expect safe care and services ...Patients have the right to be informed about outcomes of care including undesired and unexpected occurrences ...” Review of hospital policy, “Patient Observation Guidelines,” revised 1/2026, revealed, “...It is the policy of [named psychiatric hospital] to provide a safe and secure environment for patients during their hospitalization. All patients will be routinely observed in compliance with physician orders and prescribed protocols. A level of observation is defined as a level of staff awareness and attention to patient safety/security needs requiring specific protocols and documentation. Level of Observation procedures can be initiated by physicians/LIP or nurses when a patient is considered to be at increased risk for facility identified high risk behaviors... The physician shall order one of four (4) levels of observation at the time of admission and may change the level of observation if the patient ’ s condition warrants a change: A. Q [every]15 minute B. One to One C. Two to One D. Three to One... The licensed nurse or physician/Licensed Independent Practitioner (LIP) should determine the level of risk associated with each new admission and throughout their hospitalization by completing a clinical assessment which includes past behavior, present situations, and current mental status prior to assignment of a level of observation. All patients are on a minimal of 15 minute checks at admission unless otherwise indicated in the physician order.... while Mental Health Technicians [MHT] are monitoring hallways and patient care areas, they are to ensure that patients are not entering rooms not assigned to them...” 2. Review of Medical Record for Patient #1 revealed an involuntary admission date of 4/15/2026 with diagnoses which included Gross Confusion, Psychosis (loss of contact with reality), Agitation (severe restlessness, irritability, or mental distress), Delusions (fixed false belief despite clear evidence), and Positive Drug Screens for tetrahydrocannabinol ((THC)- the primary psychoactive substance in cannabis, producing intoxicating effects, euphoria, and altered perception] and Fentanyl (a highly potent synthetic opioid used to treat pain). Review of Master Treatment Plan Update/Clinical Staffing Worksheet dated 4/17/2026, revealed Patient #1 was “...attacked by peer [Patient #2] ...Nose broken...x-ray confirmed...” During an interview, on 4/30/2026 at 9:35 AM, MHT #1 stated she had worked the 7:00 PM - 7:00 AM shift on 4/17/2026. MHT #1 stated she and MHT #9 were performing patient rounds when they observed Patient #2 in the hallway talking to other patients. MHT #1 stated during the shift she observed Patient #2 walk into Patient #1 ’ s room and heard Patient #2 ask for Patient #1 for her clothes. MHT #1 stated that ’ s when she and MHT #9 walked to Patient #1’s room. MHT #1 stated she observed Patient #2 punch Patient #1 in the face. MHT #1 stated she proceeded to remove Patient #2 from Patient #1 ’ s room. Review of the Discharge Note for Adult Services dated 4/28/2026 at 12:20 PM revealed Patient #1 was discharged home. The psychiatric hospital’s staff failed to ensure the needs of Patient #1 was met when the staff failed to provide safety and protect Patient #1 ’ s physical and emotional health when Patient #2 entered Patient #1 ’ s room while she slept in her bed. Patient #1 was inpatient from 4/15/2026 - 4/28/2026. There was no documentation the psychiatric hospital ’ s staff made observations of Patient #1 based on physician ’ s order for her level of observation. There was no documentation the level of observation for Patient #1 changed based on the changing needs of the patient. 3.Review of Medical Record for Patient #2 revealed an admission date of 4/12/2026 with diagnoses which included Schizoaffective Disorder (a mental illness that affects how a person thinks, feels and behaves), Bipolar Disorder (mental illness characterized by increased irritable mood, increased energy, decreased need for sleep, rapid speech and risky behaviors, at times alternating with periods of depression), and Cannabis (marijuana) Use Disorder. Review of Master Treatment Plan Update/Clinical Staffing Worksheet, dated 4/20/2026, for Patient #2 revealed, “...on 4/17/2026 Patient #2 assaulted [Patient #1] and broke peer ’ s [Patient #1] nose because she [Patient #1] was wearing her [Patient #2] clothes...” Review of the observation log dated 4/17/2026 revealed the following observations and behaviors were documented for Patient #2 from 9:52 PM to 10:09 PM. At 9:52 PM, Pt #2 was in the patio/yard and was calm; At 10:07 PM, Pt #2 was in the bedroom and appears sleeping on right; At 10:09 PM, Pt #2 was in the bedroom and appears sleeping on right. There was no documentation at 10:10 PM of Patient #2 walking the hallway and at 10:11 PM entering Patient #1 ’ s room assaulting Patient #1. There was no documentation of any audits of why there were discrepancies in documentation showing Patient #2 was sleeping and was seen on video surveillance up walking the hallway. During an interview, on 4/28/2026 at 9:43 AM, Mental Health Technician (MHT) #7 stated while performing patient rounds during the night shift on 4/17/2025, she heard Patient #2 fussing with Patient #1 about her clothes. MHT #7 stated she had already made rounds on Patient #1 and walked back to Patient #1 ’ s room when she heard the fussing. MHT #7 stated she found Patient #1 crying and Patient #2 demanding that Patient #1 return her clothes. During an interview on 4/28/2026 at 10:35 AM, MHT #8 stated Patient #2 went down the hall complaining her clothes that had been washed, were missing. Patient #2 was wandering around the hall and said if she did not find her clothes, she would do something to get in seclusion. Patient #2 then went to Patient #1 ’ s room. MHT #8 was not aware of Patient #1 or Patient #2 being on any increased precautions or observations. The psychiatric hospital ’ s staff failed to ensure the needs of Patient #1 was met when the staff failed to provide safety and protect Patient #1 ’ s emotional and possible physical health when Patient #2 entered Patient #1 ’ s room looking for her clothes. Review of the Discharge Summary for Patient #2 revealed a discharge dated of 4/23/2026. Patient #2 was inpatient from 4/12/2026 - 4/23/2026. There was no documentation the psychiatric hospital ’ s staff made observations of Patient #2 based on physician ’ s order for her level of observation. There was no documentation the observation level of Patient #2 changed based on the changing needs of the patient.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 35244 Based on policy review, medical record review and interview, the psychiatric hospital failed to accept the transfer of one patient, out of 21 sampled patients, Patient #21, who required inpatient psychiatric treatment for an Emergency Medical Condition. The findings included: Patient #21 was a 70 year old male who presented to Hospital #2’s Emergency Department (ED) via ambulance on 10/2/2025 at 6:04 PM. The triage assessment completed on 10/2/2025 revealed Patient #21 was suicidal and had taken a ‘handful’ of Fiorcet (medication to treat tension headaches). A Medical Screening Exam (MSE) completed by Hospital #2 determined the patient was medically clear for inpatient psychiatric admission. Hospital #1 had confirmed a bed was available and accepted Patient #21 for inpatient admission. After a short time, a nurse from Hospital #1 notified Hospital #2 the physician had declined Patient #21’s admission. Patient #21 was not admitted to Hospital #1 and was later transferred to another medical facility for stabilization of a psychiatric condition. Cross Refer to A-2411.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 35244 Based on policy review, medical record review and interview, Hospital #1 failed to accept an appropriate transfer for 1 of 21 (Patient #21) sampled patients reviewed. The findings included: 1. Review of Hospital #1’s “EMTALA-Medical Screening Examination and Stabilization Policy” (7/2021) revealed, “...[Hospital #1] must accept the transfer of someone from another hospital ED [Emergency Department] where: 1. The person has an emergency psychiatric condition. 2. The transferring hospital cannot fully stabilize or treat the emergency psychiatric condition. 3. [Hospital #1] has the specialized capability to stabilize and treat the emergency psychiatric condition, and 4. [Hospital #1] has the capacity (i.e. beds, equipment, and staff) to treat the person ...” Review of Hospital #1’s “Admission/Exclusionary/Continued Stay/DC [Discharge] Criteria” policy (11/2023) revealed, “...DO NOT ADMIT A PATIENT WHO ...Requires cardiac monitoring ...THE FOLLOWING PATIENTS MAY NEED MEDICAL CLEARANCE BEFORE ADMISSION-(REVIEW WITH INTERNAL MEDICINE/HOUSE SUPERVISOR) ...Blood pressure reading of systolic > [greater than] 180 and/or diastolic > 110 ...Has overdosed in the last 24 hours and has NOT been medically cleared ...” 2. Medical record review revealed Patient #21 was a 70 year old male who presented to Hospital #2’s ED via ambulance on 10/2/2025 at 6:04 PM. A triage assessment documented Patient #21’s chief complaint was “suicidal”. Patient had taken a handful of Fioricet (used to treat tension headaches) tablets around 4:45 PM. Triage vital signs revealed blood pressure of 172/78 (a normal blood pressure for adults is generally considered to be less than 120/80) and heart rate of 74. A Medical Screening Exam (MSE) was initiated at 6:30 PM by Hospital #2’s ED Physician #1. The MSE documentation revealed Patient #21 had taken a handful of Fioricet with suicidal intentions. Patient complained of headache. Patient had multiple suicide attempts since January 2025. The Patient had a history of stroke two weeks prior to arrival to the ED. Patient #21 was non-compliant with medications and stated he would not voluntarily check himself into a mental health facility. Review of systems revealed all systems were negative other than the Patient’s complaint of headache. Patient’s past medical history documented Cancer, Hepatitis C, Heart Attack, Hypertension and Stroke. Patient #21 received Toradol (non steroid anti-inflammatory medication), Imitrex (medication for migraine headaches) and Ibuprofen (non steroid anti-inflammatory medication) while in the ED at Hospital #2. Poison control was called at 7:04 PM by Hospital #2’s ED. Poison control recommended a Complete Blood Count (CBC), Complete Metabolic Profile (CMP), alcohol level, urine drug screen, acetaminophen level, and salicylate level (which had all been drawn in the ED). Poison control also recommended a repeat acetaminophen level to be repeated in 4 hours. A second acetaminophen level was ordered; at 10:10 PM the results were received. The second acetaminophen was less than 3.0 micrograms (mcg)/milliliter (ml) (reference range was less than 10) which was within normal parameters. An electrocardiogram (EKG - a quick, painless test that records the heart’s electrical activity to check its rate and rhythm, diagnose problems, previous heart attacks, or heart damage, and monitor treatments) performed in the ED for Patient #21 on 10/2/2025, revealed sinus bradycardia (slow heart rate), left ventricular hypertrophy (thickening of the heart muscle) with repolarization abnormality. Repeat vital signs at 9:25 PM on 10/2/2025 revealed Patient #21’s blood pressure was 148/69. Review of ED Nurse #1’s note at 11:25 PM on 10/2/2025 revealed a call was received from Region 4 (behavior health crisis management for Mississippi) that Hospital #1 had a male geriatric bed available and chart would be faxed to Hospital #1 for review. ED Physician #1’s note at 11:59 PM on 10/2/2025 revealed Patient #21 was cleared medically. Repeat vital signs at 12:20 AM on 10/3/2025 revealed Patient #21’s blood pressure was 170/70. Review of ED Nurse #2’s note at 1:28 AM on 10/3/2025 revealed a nurse from Hospital #1 called and stated a repeat Tylenol level was needed, based on poison control recommendations, and wanted to know what was being done to rule out a stroke. Review of ED Nurse #3’s note at 2:11 AM on 10/3/2025 revealed ED nurse #3 called Hospital #1 Nurse. ED Nurse #3 informed Hospital #1 Nurse that Tylenol level was adequate per poison control recommendations. Also attempted to explain stroke history was not relevant due to Patient #21 had no signs or symptoms of a stroke. The Patient’s reason for coming to the ED at Hospital #2 was he was trying to harm himself. ED Nurse explained to Hospital #1 Nurse that Patient had a chronic basilar infarct (long-term blockage of the basilar artery in the brain) with no deficits. Nurse at Hospital #1 did not agree and “demanded unnecessary testing”. ED Nurse #3 attempted to have an ED physician and nurse practitioner discuss ED findings with Hospital #1 Nurse, who refused. Hospital #1 Nurse called back 5 minutes later and stated a [named physician] declined Patient but did not give reason. ED Nurse #3 then reached out to Region 4 who also attempted to speak with Hospital #1 Nurse, with no change in decision. Patient #21 was denied placement at Hospital #1. Region 4 then began the process of finding alternative placement for Patient #21. On 10/3/2025 at 10:20 AM, Patient #21 was accepted at Hospital #3. Patient #21 was transferred and transported by Emergency Medical Services (EMS) to Hospital #3 on 10/3/2025 at 11:47 AM. 3. Review of a “[Hospital #1]-Inquiry Call Data Collection” form (intake referral form) dated 10/2/2025 at 11:47 PM revealed a call was received from Region 4, “[named Region 4 employee]” in [named city/state]. Patient #21’s name, address, date of birth and emergency contact was documented. Reason for call was “SUA [suicide attempt] took handful of Fioricet. Hx [history] of attempts since Jan [January]”. Medical problems were documented as stroke, Hypertension, cancer and Hepatitis C. Hospital #1’s Inquiry Call Data Collection form documented on 10/3/2025 at 12:11 AM, “[named physician]”, MD (Hospital #1 physician) accepted Patient #21. At 12:12 AM referral source (Hospital #2) notified. Follow up notes on 10/3/2025 at 12:40 AM revealed Hospital #1 Nurse documented, “Need repeat Acetaminophen level, EKG [electrocardiogram] & [and] cardio [cardiovascular] disp [disposition], up to date VS [vital signs] over last 4 hrs [hours], nursing ...Notes stating Poison Control recommendations & what was done to r/o [rule out] stroke complications due to having stroke 2 wks [weeks] ago ...12:54 AM Requested Medical ...” Nursing Notes dated 10/3/2025 (no time documented) documented, “Pt [patient #21] denied Per NP [nurse practitioner]/Dr [doctor] [named physician] due to medical acuity ...” 4. Review of Hospital #1’s five adult units for the bed capacity on 10/3/2025 revealed there were beds available on all of the five adult units. 5. In an interview on 12/2/2025 at 8:45 AM, Hospital #1’s Director of Quality Corporate Compliance verified Patient #21 was denied due to medical acuity. In an interview on 12/2/2025 at 1:30 PM, Hospital #1’s assistant Chief Executive Officer (CEO) stated the intake nurse reviewed medical records of possible transfers. If the nurse had concerns, she or he would take them to the nurse practitioner working intake, to also review. The nurse practitioner would help make a determination to accept the transfer, or if more information was needed from the outside hospital. The nurse practitioner might reach out to a physician for verification or more guidance if needed. In an interview on 12/4/2025 at 11:25 AM, Hospital #1 Nurse stated she didn’t remember specifics about the Patient. She thought she remembered his blood pressure was too high to be accepted from Hospital #2 to Hospital #1. Hospital #2 needed a recheck of vitals, and Patient #21 needed cardiac clearance. Hospital #1 Nurse stated the nurse practitioner looked at the medical record information also, and agreed to decline. Hospital #1 Nurse stated, “We asked the hospital for more information and they refused to send us what we asked for”. Hospital #1 Nurse verified they declined transfer due to the patient was too medically acute. She did remember the physician at Hospital #2 said the patient was clear, but she told them she had to follow their policy and protocols. In an interview on 12/8/2025 at 9:40 AM, Nurse Practitioner (NP) #1 who worked at Hospital #1 stated accepting a transfer could sometimes be dependent on a patient’s medical history or what was going on in the ED. The patient might need cardiac clearance or more labs, which she thought was the issue with Patient #21. If a patient had multiple co-morbidities, that could affect if they could accept the patient at Hospital #1. NP #1 stated the majority of the time, the decline was for the “moment”. They would ask for more information, ask the ED to get certain things stable, then revisit again. NP #1 stated they did not have the ability to monitor patients (cardiac) and that could result in a short term denial. A patient would be denied until stable and no need for monitoring. In an interview on 12/9/2025 at 11:50 AM, Physician #1, who worked at Hospital #1, stated their criteria (for accepting patients) came from scope and practice. What he could recall about Patient #21 was their concern for stroke two weeks prior. Patient #21 had overdosed on Fioricet. Initially the nurse told him no second Tylenol level was drawn yet. Patient #21’s EKG showed Bradycardia and his blood pressure in the 170’s (systolic). Physician #1 said it seemed like ED stabilization was ongoing. Physician #1 stated his role as clinical collaborator was to give advice. Physician #1 did not recall declining Patient #21. Physician #1 stated Hospital #1 was an independent psychiatric facility and not a skilled facility. In an interview on 12/9/2025 at 2:05 PM, Hospital #2’s ED Nurse #3 stated he called Region 4 and gave report about Patient #21 then called and spoke with Hospital #1 Nurse. Hospital #2’s ED Nurse #3 stated, “she’s very interesting ...she’s not a nurse practitioner, not a MD [medical doctor], but acted like she had the final say so...”. Hospital #2’s ED Nurse #3 stated he tried to explain to Hospital #1 Nurse that there were no concerns with the Patient’s stroke since it was found to be “chronic” and had not been an acute event. Patient #21 was fully ambulatory. Hospital #2’s ED Nurse #3 stated he felt like Hospital #1 Nurse refused to listen to him and asked for things that were totally unnecessary. In an interview on 12/10/2025 at 4:30 PM, Region 4 Employee #1 stated she began looking for placement for Patient #21 around 11:08 PM on 10/2/2025. Hospital #1 said they had a geriatric bed available and a [named doctor] agreed to accept the Patient. Around 1:40 PM Region 4 Employee #1 called Hospital #1 to speak with Hospital #1 Nurse. Region 4 employee #1 stated Hospital #1 Nurse was rude, talked over her and seemed to have a god complex. Hospital #1 Nurse wouldn’t give her a reason as to why they were declining the Patient. Hospital #1 declined to accept a transfer of a Patient with suicide attempt from Hospital #2. Hospital #1 had the capacity to accept the Patient #21. Hospital #1 documented declining of Patient #21 due to medical acuity. Hospital #2 medically screened the Patient and found him to be medically stable for transfer to Hospital #1. There was no documentation of medical symptoms that would indicate the Patient was not appropriate for transfer to and receive inpatient treatment for a psychiatric medical condition at Hospital #1.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 49575 Based on facility document review, policy review, video recording review, medical record reviews, observations and interview, the Governing Body failed to be effective in carrying out its responsibilities for the conduct of the hospital and ensure the hospital’s ongoing compliance with all Conditions of Participation in order for quality of care to be provided to all patients. The failure of the Governing Body to carry out its responsibility for the oversight of the conduct of the hospital and failure to ensure all hospital policies and procedures to protect the safety and health of patients and prevent serious outcomes placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being. The Governing Body’s failure to manage the hospital functions, improve processes to ensure quality of care and ensure an environment of safety resulted in 4 of 9 (Patient #1, #3, #6 and #7) sampled patients not receiving protective and safe care from the behavioral health hospital. The findings included: 1. Review of the hospital’s policy, “Patient Abuse or Neglect”, last revised 8/2024, revealed the facility “will afford to patients the highest standards of clinical practice and human dignity. Staff members will demonstrate kindness...regardless of the patient’s behavior...Inappropriate staff conduct may include, but is not limited to: Any physical violence which may result in injury such as...rough handling...Not performing duties safely...” Review of the hospital’s policy, “Patient Observation Guidelines,” last revised 07/2024, revealed “It is the policy of [Facility #1] to provide a safe and secure environment for patients during their hospitalization... Observation is defined as a level of staff awareness and attention to patient safety/security needs requiring specific protocols and documentation...If a patient’s behavior/mood necessitates a more intensive level of observation, the Charge Nurse may initiate a higher degree of observation upon assessment. The physician/LIP [Licensed Independent Practitioner] is to be notified as soon as possible and an order written. The Charge nurse will notify all staff working with the patient of the observation change...While monitoring hallways and patient care areas, Mental Health Technicians (MHT) ensure patients are not entering rooms not assigned to them...Observe patients...when sleeping by...making sure that the patient has moved from his/her previous sleeping position...Ensure doors that are to be locked are, in fact, locked...” Review of the hospital’s policy “Vital Signs” last revised 11/2023 revealed, “...All patients...will have vital signs taken...as...warranted by patient’s condition. Vital sign include temperature, pulse [heart rate (HR) - number of times the heart beats in a minute; a normal resting HR for a healthy adult is between 60 and 100 beats per minute], respirations, blood pressure [BP - the force of blood pushing against artery walls as the heart pumps blood throughout the body; a normal BP is 120/80], and O2 sat [oxygen saturation - which is the percentage of oxygen in the blood; normal O2 sat for a healthy adult is 95% to 100%]. Vital signs are the responsibility of the nursing staff assigned to the patient. The charge nurse is to be informed of vital signs that are outside of the documented parameters for the facility. The Registered Nurse [RN] on the unit should always use clinical judgement as to whether to contact the medical provider...” Review of the hospital’s policy, “CPR [(Cardiopulmonary Resuscitation) - an emergency procedure that involves chest compressions and mouth-to-mouth breathing used when someone has stopped breathing or the heart has stopped beating]”, last revised 12/2023, revealed “...All CPR certified personnel have the responsibility for initiating emergency resuscitation in the event that it is required, following current American Heart Association Guidelines. The first staff member on the scene has responsibility for: 1. Assessing for responsiveness, gently shake the patient and shouting his/her name. 2. Shouting CODE BLUE [emergency code that indicates a patient is in critical condition and needs immediate medical attention], noting the time. 3. Establishing airway, clearing mouth. 4. Checking carotid pulse, if absent begin external cardiac compression...” 2. Review of the “Patient Admission Information” form dated 8/13/2024, revealed Hospital #1 is “... dedicated to providing a safe environment for its patients and staff...” 3. Review of the “Job Descriptions” for the Charge Nurse, Registered Nurse (RN), Licensed Practical Nurse (LPN), Mental Health Technician (MHT) and Certified Nursing Assistant (CNA), not dated, revealed the staff are to “...adhere to all hospital policies and procedures and report all accidents immediately to their supervisor...have the ability to exercise self-control in potentially volatile situations...Demonstrates knowledge and use of infection control/universal precaution principles to prevent exposure to and transmission of disease...Is slow to respond, therapeutic and thoughtful in response when patients direct anger, frustration, and other extreme emotions directly to you...” 4. The Governing Body failed to ensure patients’ rights to receive care in a safe setting were followed for Patients #1, #3, #6 and #7. Patient #1 was found unresponsive in the dayroom. There was no documentation the physician and/or nurse had been notified of the patient’s decrease in blood pressure and oxygen saturation levels (normal is 90-100% of oxygen in the bloodstream) the four days prior to the patient being found unresponsive. Patient #3 demonstrated aggressive behavior and was taken to seclusion. Observations of the hospital’s video recording revealed Patient #3 was pushed into the seclusion room by the staff. Patient #6 experienced low oxygen saturation for 2 days. There was no documentation of reassessments by the nurse nor physician/nurse practitioner notification of the patient’s low blood pressure and oxygen saturations. Patient #7 experienced low blood pressure and low oxygen saturations for 30 days. There was no documentation of reassessments by the nurse nor physician/nurse practitioner notification of the low oxygen saturations until she developed wheezing. Patient #7 was transferred to a local hospital where the Patient was admitted with Pneumonia. Refer to A 115 and A 144. 5. The Governing Body failed to ensure Nursing Services adhered to facility policies to protect vulnerable Patients #1, #3, #6 and #7 from actual and/or potential harm. Nursing staff failed to perform assessments and reassessments of patients who were experiencing a decline in their vital signs and failed to notify the patients’ physician and/or nurse of the patients’ decline in vital signs. Patient #1 was found unresponsive and required CPR after experiencing 4 days of a decline in their vital signs without physician and/or nurse notification of the decline in the vital signs. Patient #7 experienced a decline in their vital signs for 30 days without physician and/or nurse notification and was transferred to the hospital with pneumonia. Patient #6 experienced a decline in their oxygen saturation and there was no physician notification. Nursing failed to protect all patients from all forms of abuse when staff were observed pushing on Patient #3 in order to get the Patient to go into the Seclusion Room. Refer to A-115, A-144, A-385 and A-395.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49575 Based on facility policy review, document review, medical record review, video recording review and interviews, the facility failed to ensure patients’ rights were promoted for 4 of 9 (Patient #1, Patient #3, Patient #6, and Patient #7) sampled patients reviewed. The findings included: 1. The Behavioral Health Hospital failed to ensure Patient #1 received care in a safe setting when his blood pressure readings and oxygen saturation declined over a four day period (8/13/2024 - 8/17/2024) without any documentation of notification to the physician/nurse practitioner; On 8/17/2024, Patient #1 was found unresponsive in the dayroom and staff was unable to revive him. Emergency Medical Services (EMS) was called to the Behavioral Health Hospital, transferred to a local hospital and pronounced deceased at the local hospital. 2. The faciity failed to ensure Patient #3 received care in a safe setting when she became aggressive and tried to attach staff, Registered Nurse # and Mental Health Technician # took Patient #3 to the seclusion room. The RN and MHT were viewed on video to be pushing and pulling on Patient #3 to get her into the seclusion room and close the door. 3. The facility failed to ensure Patient #6 received care in a safe setting when the patient experienced low blood pressure and low oxygen saturation over a two days (10/2/2024 and 10/3/2024) without any documentation of notification to the physician/nurse practitioner. 4. The facility failed to ensure Patient #7 received care in a safe setting when the patient’s blood pressure was low and oxygen saturation unstable from 9/13/2024 - 10/14/2024 with no documentation of reassessment of the vital signs, no reassessment of the patient or notification of the physician or nurse practitioner. On 10/14/2024, the patient was found to be wheezing when in the dayroom. The patient was transferred to a local hospital and admitted with diagnosis of Pneumonia. Refer to A-0144”

“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: 49575 Based on policy review, document review, review of video footage, medical record review, and interview, the behavioral health hospital failed to provide Nursing services to meet the patients’ needs and ensure patients received necessary care and services for 4 of 9 (Patient #1, #3, #6, and #7) sampled patients who experienced a decline in their vital signs and the physician and/or nurse were not notified, assessments and reassessments were not performed by staff when patients experienced a decline in their vital signs, and when staff handled patients aggresively when escorting patiens to the seclusion room. The findings included: 1. The behavioral health hospital failed to notify the physician/nurse practitioner of Patient #1’s decreased blood pressure and oxygen saturation for a four-day. On the fourth day (10/17/2024), the patient was up in a geri-chair in the dayroom when he was found unresponsive. The nursing staff was unable to revive Patient #1 after cardiopulmonary resuscitation was started. Emergency Medical Services were called and the patient was transported to the local hospital where the patient was pronounced deceased. 2. The behavioral health hospital failed to ensure Patient #3 was allowed to go into the seclusion room under her own willpower after she was aggressive and was hitting at staff. The Registered Nurse and Mental Health Technician were viewed on video to push and pull-on Patient #3 to make her go into the seclusion room. 3. The behavioral health hospital failed to notify the physician/nurse practitioner of Patient #6 and Patient #7’s decreased blood pressure and oxygen saturation. Patient #7 was transferred to a local hospital after developed wheezing. Patient #7 was admitted to the hospital with a diagnosis of Pneumonia. Refer to A-115, A-144, and A-395”

“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: 49575 Based on facility policy review, document review, medical record review, video recording review, and interview, the facility failed to ensure patients had the right to receive care in a safe setting for 4 of 9 (Patient #1, #3, #6, and #7) sampled patients. The findings included: 1. Review of the facility’s policy, “Patient Abuse or Neglect”, last revised 8/2024, revealed the facility “will afford to patients the highest standards of clinical practice and human dignity. Staff members will demonstrate kindness...regardless of the patient’s behavior...Inappropriate staff conduct may include, but is not limited to: Any physical violence which may result in injury such as...rough handling...Not performing duties safely...” Review of the facility’s policy, “Patient Observation Guidelines,” last revised 07/2024, revealed “It is the policy of [Facility #1] to provide a safe and secure environment for patients during their hospitalization... Observation is defined as a level of staff awareness and attention to patient safety/security needs requiring specific protocols and documentation...If a patient’s behavior/mood necessitates a more intensive level of observation, the Charge Nurse may initiate a higher degree of observation upon assessment. The physician/LIP [Licensed Independent Practitioner] is to be notified as soon as possible and an order written. The Charge nurse will notify all staff working with the patient of the observation change...While monitoring hallways and patient care areas, Mental Health Technicians (MHT) ensure patients are not entering rooms not assigned to them...Observe patients...when sleeping by...making sure that the patient has moved from his/her previous sleeping position...Ensure doors that are to be locked are, in fact, locked...” Review of the facility’s policy “Vital Signs” last revised 11/2023 revealed, “...All patients...will have vital signs taken...as...warranted by patient’s condition. Vital sign include temperature, pulse [heart rate (HR) - number of times the heart beats in a minute; a normal resting HR for a healthy adult is between 60 and 100 beats per minute], respirations, blood pressure [BP - the force of blood pushing against artery walls as the heart pumps blood throughout the body; a normal BP is 120/80], and O2 sat [oxygen saturation - which is the percentage of oxygen in the blood; normal O2 sat for a healthy adult is 95% to 100%]. Vital signs are the responsibility of the nursing staff assigned to the patient. The charge nurse is to be informed of vital signs that are outside of the documented parameters for the facility. The Registered Nurse [RN] on the unit should always use clinical judgement as to whether to contact the medical provider...” Review of the facility’s policy, “CPR [Cardiopulmonary Resuscitation - an emergency procedure that involves chest compressions and mouth-to-mouth breathing used when someone has stopped breathing or the heart has stopped beating]”, last revised 12/2023, revealed “...All CPR certified personnel have the responsibility for initiating emergency resuscitation in the event that it is required, following current American Heart Association Guidelines. The first staff member on the scene has responsibility for: 1. Assessing for responsiveness, gently shake the patient and shouting his/her name. 2. Shouting CODE BLUE [emergency code that indicates a patient is in critical condition and needs immediate medical attention], noting the time. 3. Establishing airway, clearing mouth. 4. Checking carotid pulse, if absent begin external cardiac compression...” 2. Review of the “Patient Admission Information” form dated 8/13/2024, revealed Facility #1 is “... dedicated to providing a safe environment for its patients and staff...” Review of the “Job Descriptions” for the Charge Nurse, Registered Nurse (RN), Licensed Practical Nurse (LPN), Mental Health Technician (MHT) and Certified Nursing Assistant (CNA), not dated, revealed the staff are to “...adhere to all hospital policies and procedures and report all accidents immediately to their supervisor...have the ability to exercise self-control in potentially volatile situations...Demonstrates knowledge and use of infection control/universal precaution principles to prevent exposure to and transmission of disease...Is slow to respond, therapeutic and thoughtful in response when patients direct anger, frustration, and other extreme emotions directly to you...” 3. Medical record review revealed Patient #1 was transferred from Facility #2 (a skilled nursing facility(SNF)) and involuntarily admitted to Facility #1 on 8/13/2024. Review of the “Standardized Intake Assessment - Direct Admissions” dated 8/13/2024, revealed Patient #1 was involuntary admitted from a SNF to Facility #1. Patient #1 was referred by the SNF due to to escalating verbal and physical aggression, making sexually inappropriate comments to the staff and attempting to hit them. The intake assessment further documented the patient needed medication stabilization. The “Psychiatric Evaluation” dated 8/14/2024, revealed Patient #1 was a 59-year-old male with Dementia and Behavioral Disturbances. The patient’s chief complaint in his own words was, “I was at the nursing home and they sent me over here.” The patient was oriented to person and place. The patient was very aggressive and sexually inappropriate. The patient demonstrated labile mood and behavior, temper outbursts and verbally assaulting peers. Patient #1 was confused, would forget limitations, and was a high fall risk. The patient was experiencing suicidal thoughts, and wished to be dead. He also had homicidal thoughts toward the nursing home staff and wandered into other patient’s rooms, threatening them. The patient had delusions related to dementia. He has a medical history of Diabetes Mellitus, COPD (Chronic Obstructive Pulmonary Disease; a group of lung diseases that block air flow and make it difficult to breathe), Cirrhosis of the Liver, Hyperlipidemia (an excess of lipids or fats in the blood), Atherosclerosis (Atherosclerosis is the buildup of fats, cholesterol, and other substances in and on the artery walls) and a history of alcoholism and smoking. Patient #1 required assistance with ambulation, bathing, dressing and grooming and was assessed with a severe level of disability. Review of the “High Risk Notification Alert” dated 8/13/2024 at 1:25 PM revealed Patient #1 had a medically compromised risk due to COPD. There was no documentation his oxygen saturation was assessed prior to the transfer to his assigned room. Medical record review for Patient #1 revealed the following: On 8/13/2024, there was no documentation the patient’s O2 sat was monitored for a baseline at the time of admission. (The normal O2 sat for a healthy adult is 95% to 100%). On 8/14/2024, at 11:06 AM - O2 sat - 91%. There was no documentation a physician or LIP (licensed independent practitioner) was notified of the below normal O2 sat. On 8/15/2024, at 8:10 PM.- O2 sat - 79%; Blood Pressure (BP) -89/53. There was no documentation a physician or LIP was notified of the below normal BP or O2 sat. On 8/15/2024, at 8:11 PM - BP - 92/45. There was no documentation a physician or LIP was notified of the below normal BP. On 8/15/2024, at 8:12 PM -O2 sat - 92%; BP - 91/44. There was no documentation a physician or LIP was notified of the below normal O2 sat or BP. On 8/15/2024, at 8:14 PM - O2 sat - 93%; BP - 88/41. There was no documentation a physician or LIP was notified of the below normal BP or O2 sat. On 8/15/2024, at 8:20 PM - O2 sat - 94%. There was no documentation a physician or LIP was notified of the below normal O2 sat. On 8/16/2024, at 7:13 AM - O2 sat - 90%; BP - 87/50. There was no documentation a physician or LIP was notified of the below normal O2 sat and BP. On 8/16/2024, at 7:04 PM - O2 sat - 78%; BP - 151/119; Heart Rate (HR) - 203. There was no documentation a physician or LIP was notified of the below normal O2 sat and the elevated BP. On 8/16/2024, at 10:26 PM - O2 sat - 78%. There was no documentation a physician or LIP was notified of the below normal O2 sat. On 8/17/2024, at 8:00 AM - O2 sat - 84%; BP - 183/110; HR - 157. There was no documentation a physician or LIP was notified of the below normal O2 sat, elevated BP and HR. On 8/17/2024, at 10:40 AM - BP - 183/110. There was no documentation a physician or LIP was notified of the elevated BP. Review of the “Incident Report,” dated 8/14/2024 at 10:30 PM, revealed, “This PT [Patient #1] got in another pt bed, other pt became aggressive towards this pt [Patient #1]. This pt [Patient #1] appears to have bluish-purple discoloration noted under his left eye with a small amount of blood noted to his nose...” Review of the “Incident Report” dated 8/15/2024 at 2:50 PM, revealed, “... it was observed that [Patient #1] was agitated and put himself on the floor...” There was no documentation Patient #1 was injured during this incident. Review of a “Nursing - Daily Progress Note 8 HR Shift” revealed the following: “...8/17/2024 11:00 AM Patient [Patient #1] found on floor in restroom. Denies pain or discomfort. No injuries noted. MD [Medical Doctor] notified. No new orders... 8/17/2024 at 1731 [5:31 PM] Patient noted in dayroom, lethargic and SOB [short of breath] cough (non-productive) noted. Patient placed on O2 [oxygen] at 2 LBNC [liters by nasal cannula]. Stat [immediately] CXR [chest x-ray] 2-view, covid swab stat, Prednisone 30 mg [miligrams] now...Rocephin [antibiotic] 1 gm [gram] IM [intramuscularly] now. Family notified...” Review of the “Medical Response Team Documentation” dated 8/17/2024, revealed the Medical Response Team (MRT) was initiated at 5:55 PM and first responders arrived at 6:00 PM. “... Descriptors of events up to time of call: pt [Patient #1] noted to have a congested airway and a cough with difficulty breathing. O2 started per N.P. [Nurse Practitioner] and meds [medications] ordered. Pt got worser [worse] and CPR had to be started... Early Warning Sign...Acute Mental Status Change...Change in LOC [level of consciousness]...Airway Management - ambu bag [handheld device that provides positive pressure ventilation to patients who are not breathing or not breathing adequately]...Additional notes - CPR started... MRT completed call - pt [Patient #1] transferred to [named Hospital] via ambulance... moved to higher level of care...” Review of the “Code Blue [a hospital emergency code that indicates a patient is in critical condition and needs immediate medical attention] R.N. Documentation” dated 8/17/2024 at 5:55 PM revealed, “... Reason for code/condition of patient: Patient found unresponsive in the dayroom at 1755 [5:55 PM] unable to obtain vital signs. Unresponsive to verbal/tactile stimuli [tactile stimuli is connected with the sense of touch]. Code blue initiated and CPR started...AED [Automated external defibrillators - portable, life-saving devices designed to treat people experiencing sudden cardiac arrest] Initiated - ‘yes’...AED Time started: 1757 [5:57 PM]...number of shocks delivered - 0; patient response: unresponsive, no pulse...Patient found unresponsive in dayroom at 1755 [5:55 PM]...” Review of an “Incident Report,” dated 8/17/2024 at 5:55 PM, revealed that Patient #1 was “observed in room unresponsive, no pulse and not breathing, Code MRT called and then Code Blue called, and CPR initiated immediately. 911 called continued [cpr] until 911 arrived and took over and then pt [Patient #1] was transported to [Hospital #1] by [named ambulance service]...” Review of a “Progress Record” revealed, “... 8/17/2024 1804 [6:04 PM] Alerted to Code Blue on unit. On assessment patient [Patient #1] in recliner unconscious and chest compressions in progress. Patient assisted to floor by staff. 1810 [6:10 PM] Pulse check via AED - Rt [right] femoral [attempted to check pulse with palpation of right femoral artery] was negative; chest compressions resumed...1815 [6:15 PM] EMS arrived and took over code... 1833 [6:33 PM] 1755 [5:55 PM] patient found unresponsive in dayroom. MRT called. Code Blue initiated. Started CPR...1807 [6:07 PM] HR 126, BP - 111/71, 0 resp. 1813 [6:13 PM] - still no pulse. CPR continued. 1814 [6:14 PM] - 107 blood sugar. Paramedic arrived. 1822 [6:22 PM]- patient intubated and pupils fixed/dilated, no pulse. 1827 [6:27 PM - agonal breathing [a term for a pattern of abnormal breathing that indicates a severe medical emergency such as cardiac arrest or stroke]. 1830 [6:30 PM] - CPR continued 1832 [6:32 PM] - compressions/bagging continue and patient transported to [Hospital #1]...” Review of the Emergency Medical Services (EMS) report dated 8/17/2024 revealed EMS arrived at the facility at 6:13 PM. The EMS report documented, “Staff advised the Pt. had been declining today and just got an order to have a chest x-ray done due to h/o [history of] COPD and CHF [Congestive Heart Failure - a chronic condition in which the heart doesn’t pump blood as well as it should].” Review of video footage, dated 8/17/2024, revealed the following: 4:22:29 PM - MHT #3 entered the Day Room and began using a dynamap (an electronic device used to take temperature, pulse, blood pressure and oxygen saturation) to assess vital signs on Patient #1, who was sitting in a geri-chair. 4:22:29 PM to 4:26:54 PM - MHT #3 moved to the right and left side of Patient #1 while removing and replacing the pulse oximeter and blood pressure cuff. 4:46:04 PM - RN #2 approached Patient #1, placed a hand on patient’s shoulder and used the dynamap to assess vital signs and oxygen saturation 4:48 PM - RN #2 placed the manual BP cuff on Patient’s #1’s arm 4:51:30 PM - RN #5 used the dynamap to assess vital signs and placed a hand on Patient #1’s chest. 4:53:46 PM - RN #5 moved to right side of Patient #1 and touched the oxygen tank, then moved to left side of patient. 5:21 PM - MHT #3 approached Patient #1 with a food tray and placed the tray on the shelf after patient shook his head. RN #2 entered and performed a nasal swab on Patient #1. 5:42:08 PM to 5:48:22 PM - x-ray personnel were in the Dayroom and performed chest x-rays of Patient #1. 6:00 PM - RN #5 entered the Dayroom and placed tingers on Patient #1’s left wrist then left the room. 6:00:30 PM - RN #5 and RN #2 entered and approached Patient #1. RN #2 performed a sternal rub (application of painful stimulus with the knuckles of a closed fist to the center of the chest of a patient who is not alert and does not respond when his/her name is called). 6:02:26 PM - The crash cart (a cart stocked with emergency medications and supplies that are used during emergency situations such as a patient not breathing) was brought into the dayroom and taken back out. 6:02:51 PM - The House Supervisor (HS) entered the hallway. 6:03:05 PM - The HS entered the dayroom. 6:03:37 PM - Patient #1 (in the geri-chair) was moved into the hallway. 6:03:56 PM - RN #2 began chest compressions on Patient #1 while he was in the geri-chair. Staff from other units arrived on the scene to provide assistance. 6:09 PM - NP #1 arrived at the code. 6:10:24 PM - RN #7 arrived at the code, Patient #1 was placed on the floor and resuscitation efforts continued. 6:13 PM - EMS arrived, and Patient #1 was loaded for transport to higher level care. Review of the Emergency Department (ED) record from Hospital #1 dated 8/17/2024, revealed Patient #1 was seen in the ED at 6:42 PM. Patient #1, “...was brought in via EMS from [Facility #1] after found unresponsive. CPR was started on the scene per staff and continued by EMS and arrival and intubated. The cardiac monitor revealed PEA [pulseless electrical activity - a life-threatening condition where the heart has electrical activity but does not pump blood to the body] and no palpable pulse on arrival at the hospital. The patient presented with cardiac arrest from [named Facility #1]...Patient was standing, rolling [in wheelchair] at approximately 530 [PM] declined dinner and they [staff from Facility #1] went back in to check on him and he was found down, EMS arrived at 1810 [6:10 PM] started CPR initial rhythm was PEA, he received epi [epinephrine - medication given to during cardiac arrest to stimulate the heart and restore the heartbeat] x 3 [doses] and bicarb [bicarbonate - medication given during cardiac arrest to correct metabolic acidosis and improve outcomes in cardiac arrest] x 1 in the field. Patient did have a fall today and was hit in the eye yesterday. Initial rhythm here was PEA patient received Bicarb and epi was intubated and had to have IO [intraosseous - injecting fluid and medication directly into the bone marrow; used when intravenous access is not available or is not feasible] access to the EJ [external jugular - vein in the neck that drains blood from the head to the heart; may be used in an emergency situation to provide fluids to a patient who is in distress] initiallly placed by the paramedics not working...Impression: Cardiac arrest; Respiratory Arrest. Time of Death 6:49 PM.” During an interview on 9/4/2024 at 8:45 AM, RN #2 stated she worked as the charge nurse on the Geropsychiatric Unit the day [8/17/2024] of the incident involving Patient #1. When asked if Patient #1 had respiratory issues, RN #2 stated, “... he [Patient #1] had COPD. His pulse oximeter [machine used to measure oxygen saturation] reading was 94-95 before the use of the inhaler and 96-97 after use of the inhaler...didn’t check his breath sounds or respiratory rate. A few hours later, the medication nurse came to the desk and told me to check on [Patient #1]. He was short of breath and wheezing. The medication nurse came to the unit about 45 minutes later and said to come with her to the day room. [Patient #1] was unresponsive in a chair with his legs propped up in another chair...called a code, and CPR was started. Before the code was started, [Patient #1]’s brother was contacted. He [Patient #1’s brother] was very upset because his brother was in an altercation with another patient the previous day and had a black eye and earlier that morning, [Patient #1] was found in the floor of the hallway restroom. He was conscious and asking to get up... a lot of times when patients come out of the hall bathroom, the door may not close thoroughly and doesn’t lock. No one monitors the hallway bathroom. You won’t know who goes in the hallway bathroom. When [Patient #1] was found unresponsive in the day room, he was in a geri-chair [geriatric reclining chair] with his feet propped up...” When asked if she did any type of assessment of Patient #1 when he complained of shortness of breath, RN #2 reported that she, “... took his vital signs...again around 11:00 AM and they were fine...” RN #2 stated the only problem with Patient #1 at that time was his oxygen saturation was low. RN #2 stated Patient #1’s oxygen saturation was in the 80s, and he was placed on oxygen. During an interview on 9/4/2024 at 11:20 AM, the House Supervisor (HS) reported that she received a call from the nurse practitioner (no name provided) reporting that Patient #1 was having problems breathing. The HS went to the Pharmacy to pick up medication for Patient #1. When the HS arrived on the unit, there was a crash cart (cart which contains medications and supplies to respond to a medical emergency code) present. The HS stated the unit nurse had to call a code for Patient #1. The HS stated Patient #1 was sitting in a geri-chair in the dayroom with his feet elevated, and he looked like he was sleeping. The HS stated Patient #1 had no carotid (blood vessel in the neck) pulse, and the staff had initiated CPR. The HS stated she was first notified Patient #1 was having difficulty breathing around 5:30 to 5:45 PM. The HS stated she didn’t know Patient #1 had been having difficulty breathing earlier in the shift. The HS stated she did not recall being notified by staff that Patient #1 had been found in the floor in the bathroom earlier on the day the patient was found unresponsive. During an interview on 9/12/2024 at 2:05 PM, the Chief Nursing Officer (CNO) reported that the hallway bathrooms are keyed, and they have an automatic lock. The CNO stated technicians let the patients in the bathroom and monitor the door. During an interview on 10/16/2024 at 7:50 AM, Mental Health Technician (MHT) #3, reported “... recalled working with [Patient #1] around 7:00 AM and 3:00 PM. When [named Patient #1] got up to get dressed, he was short of breath when he tried to put on his pants.” When asked about his assistance with Patient #1 around 3:00 PM, MHT #3 reported, “... when he approached him [Patient #1], he [patient] had taken his oxygen off... reached for the oxygen tubing to place it on him [patient]. When he [patient] pulled the pulse oximeter off his finger and replaced it, the reading might have been too low; however, do not recall the reading or if it was too low...” When MHT #3 was asked if he recalled if he reported anything about Patient #1 to other staff at that time, MHT #3 “did not recall.” During an interview on 10/16/2024 at 8:10 AM, Nurse Practitioner (NP) #3 stated on the day (8/17/2024) of the incident, the charge nurse called her about Patient #1 being placed on oxygen. NP #3 stated the next call that she received from the nurse was to inform her that they had to perform CPR on him after he was found unresponsive. He was transferred to the hospital where he died. NP #3 stated she was never informed of the patient having a low blood pressure or low oxygen saturation at any other time during his admission at (named Facility #1). During an interview on 10/16/2024 at 8:30 AM, NP #1 reported she was working on the Gero unit on the day (8/17/2024) of the incident with Patient #1. NP #1 stated when she arrived on the unit, the staff was performing chest compressions while the patient was sitting in the geri-chair. NP #1 stated that after another nurse arrived, they were able to get Patient #1 on the floor, a hard surface, so that more effective chest compressions could be performed. During an interview on 10/16/2024 at 10:11 AM, RN #7 reported that when Patient #1 was found unresponsive, she responded to the Code Blue when it was called. RN #7 stated when she arrived on the Gero unit, staff was performing chest compressions while Patient #1 was in the geri-chair. RN #7 stated she got LPN #1 to assist with getting the patient in the floor so CPR could be continued. During an interview on 10/16/2024 at 1:30 PM, RN #5 reported that it was about 4:00 PM, when she was doing accuchecks (fingersticks to check a patient’s blood sugar) in the dayroom. RN #5 stated no one communicated anything to her about Patient #1. RN #5 stated she took Patient #1’s vital signs at 4:51 PM because the dynamap didn’t register appropriately. RN #5 stated she tried to arouse Patient #1 at 6:00 PM, but he did not respond. RN #5 attempted to check his pulse and went to inform the charge nurse that he was unresponsive. RN #5 stated she and RN #2 returned and moved Patient #1 out into the hall and began chest compressions. RN #5 stated RN #2 was directing the code. During an interview on 10/18/2024 at 9:45 AM, when questioned about documentation that Patient #1 had an oxygen saturation of 78% on 8/17/2024, LPN #3 stated that she did not recall Patient #1 having an oxygen saturation of 78%. LPN #3 stated she did not recall notifying a medical provider or NP that Patient #1 had complaints of shortness of breath, low oxygen saturations or abnormal vital signs. LPN #3 confirmed that when MHTs made rounds, they were to check the patients for breathing, safety and make sure nothing concerning was going on with them. During an interview on 10/18/2024 at 10:15 AM, RN #3 stated the MHTs and CNAs taking vital signs wee supposed to scan the patients’ bar code prior to taking the vital signs. Once the vital signs were taken with the dynamap, they are transferred in the system and to the patients’ record. The vital signs were also recorded on a log which is given to the nurse. If there was a need for vital signs to be retaken, those vital signs should also be in the system. RN #3 stated she did not recall ever having to notify a NP or MD regarding issues with Patient #1. RN #3 stated the Milieu Supervisor (MS) #1 reported that Patient #1 fell on the Friday before he died on Saturday. RN #3 stated no one had to report it to the nurse because he fell in front of the nurse’s station. RN #3 stated Patient #1 complained of not feeling good when he arrived at the nurses’ station. RN #3 stated the charge nurse (RN #6) told a staff member to take Patient #1 back to his room and have him lie down. RN #3 stated RN #6 never wrote an incident report, called the physician, or assessed Patient #1 after the fall. During an interview, on 10/30/2024 at 7:30 AM, MS #1 reported that she had received complaints from the CNAs and MHTs about RN #6. MS #1 stated the CNAs and MHTs reported that when they told RN #6 about mental status changes, breathing problems, increased temperature, or vital sign changes, she would not address the concern, and she would tell her superiors that staff never reported anything to her. MS #1 reported that Patient #1 fell in front of the nurses’ station on the Friday (8/16/2024) before he died, but she did not think anything was done about the fall. MS #1 stated Patient #1 was yelling and complaining of pain after the fall. During an interview on 10/30/2024 at 10:34 AM, RN #6 reported that when the MHTs and CNAs report abnormal vital signs to her, then she would give a copy of the abnormal vital signs to the medication nurse who typically documented the vital signs. RN #6 stated they might do a quick assessment and recheck the vital signs with the dynamap and manually. RN #6 stated when there are abnormal vital signs, she (RN #6) would ask the medication nurse and the technicians to check on the patient more frequently. When asked who would call the medical providers to report abnormal vital signs, RN #6 stated she usually placed the calls. RN #6 stated she does not usually review the patients’ charts, however; she “...try to check the vital signs when I have time. Some days are just wild. RN #6 stated that they have parameters for reporting abnormals, but if the patient was not symptomatic, she would call the nurse practitioner who would likely send the patient to the emergency room. RN #6 stated if the patient was symptomatic, she would call the medical response team and then the doctor. 4. Medical record review revealed Patient #3 was admitted to Facility #1 on 7/27/2024 with diagnoses which included Schizoaffective Disorder, Depression, and Other Stimulant Dependence. Patient #3 was voluntarily admitted to the facility and presented with suicidal ideations with no plan to commit suicide, history of physical and sexual childhood abuse, and a history of domestic violence. Patient #3 reported hearing voices telling her people were out to get her, saw things that were not there, increased anger/irritation, impulsiveness and substance abuse. Patient #3 was assessed as a danger to self and others as evidenced by family member completion of suicide (cousin), poor judgment, poor insight, and poor impulse control. Review of a “Progress Note” dated 8/9/2024 at 11:06 PM, revealed, “... Pt psychotic and aggressive...shortly after arriving to unit, pt tried attacking staff. After pt was able to calm down she was placed in seclusion at 2306 [11:06 PM]. At 0221 [2:21 AM] pt was able and willing to verbally contract for safety and therefore was taken back to her room...” Review of a “Seclusion/Restraint/Chemical Restraint Order” dated 8/9/2024 at 11:06 PM, revealed, “...type of intervention: Seclusion...Reason for intervention - Imminent Danger to others: Patient attacking staff...Less Restrictive Interventions: Verbal Des-escalation/redirection...Reality orientation...” Reveiw of the “Post Intervention Face to Face Evaluation” dated 8/9/2024 at 11:48 PM, revealed, “...Assessment of immediate situation: Pt standing in seclusion. Pt refusing to speak...Describe the patient’s response to intervention...Pt in acute psychotic episode...Mental Status/Behavioral Assessment: Thought process - flight of ideas... loose associations... circumstantial...Mood - Angry, irritable...Affect...Labile...Behavior...Uncooperative... Attitude...Belligerent...Motor Active...Increased;... Thought content: Delusions... Delusional psychotic Behaviors...” Review of the “Investigation Summary” revealed that on 8/9/2024 at 11:06 PM, revealed that during review of the video footage, RN #4 and MS #2 were seen pulling and pushing Patient #3 into the seclusion room so the door could be closed. Patient #3 was in seclusion from 11:06 PM to 2:21 AM, a total of 3 hrs and 15 minutes. During an interview on 9/12/2024 at 1:30 PM, the Director of Risk Management (DRM) reported that she reviewed the video and interviewed staff to investigate this incident. The DRM stated the video footage revealed MS #2 and RN #4 pushed and pulled Resident #3 into the seclusion room to get her into the room and closed the door. The DRM stated MS #2 was suspended pending the results of the investigation and RN #4 received a written warning and was required to attend a Handle with Care training class prior to returning to work. During an interview on 9/12/2024 at 2:05 PM, the CNO reported that she watched the video footage of the incident and participated in the discussion and interviews. The CNO stated it was an administrative decision that MS #2 would be terminated from employment. The CNO stated RN #4 got a final written warning for pulling the patient into the room. During an interview on 10/14/2024 at 11:00 AM, DON #3 confirmed during the review of the video footage, that MS #2 and RN #4 did not handle Patient #3 according to Restraint/Seclusion/Handle with Care/De-Escalation Policy. During an interview on 10/14/2024 at 11:15 AM, the CNO confirmed during the review of the video footage that RN #4 was pulling and pushing on Patient #3, and did not follow the facility’s policies for Restraint/Seclusion/Handle with Care. During an interview on 10/15/2024 at 7:50 AM, RN #4 reported that she and MS #2 gently assisted/escorted Patient #3 into the seclusion room on 8/9/2024. RN #4 denied that she pulled or pushed Patient #3 into the seclusion room. 5. Medical Record review for Patient #6’s revealed an admission date of 10/1/2024 with diagnoses that included Vascular Dementia, Behavior Disturbance, Mood Disturbance and Anxiety. Review of the “Psychiatrist Evaluation/Admission History and Examination” revealed, “...history of present illness (onset of illness and circumstances leading to admission) - 81 yo [year old]... with dementia presents with paranoia, agitation, labile mood & [and] behavior... poor insight & judgement, forgets limitation... Recently discharged & admitted to medical hospital for AKI [Acute Kidney Injury]... Medical history... Acute on Chronic CHF [Congestive Heart Failure], HTN [Hypertension], Hypothyroidism, HLD [Hyperlipidemia]...” Review of vital signs for Patient #6 revealed the following oxygen saturation levels [O2 sats]: On 10/2/2024 at 11:19 AM, O2 sat - 89%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 10/3/2024 at 11:19 AM, O2 sat - 89%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 10/3/2024 at 11:19 AM, O2 sat - 90%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. 6. Medical Record review for Patient #7 revealed an admission date of 9/25/2024 with diagnoses of Psychosis, History of Hypothyroidism, Cerebrovascular Accident, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Rule Out Early Dementia. Review of Patient #7’s vital signs revealed the following: On 9/27/2024 at 1:03 PM - BP - 89/50; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 9/28/2024 at 11:35 AM - BP - 80/44; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 9/13/2024 at 8:37 AM - BP - 87/54, O2 sat - 92%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 9/13/2024 at 10:48 AM - BP - 85/47, O2 sat - 89%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 10/12/2024 at 3:55 PM - O2 sat - 93%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 10/13/2024 at 1:48 PM - O2 sat - 94%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 10/14/2024 at 7:36 AM - BP - 73/47; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 10/14/2024 at 7:39 AM - BP - 73/48; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 10/14/2024 at 7:39 AM - BP - 74/48, O2 sat - 91%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 10/14/2024 at 7:40 AM - BP - 78/51, O2 sat - 90%; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 10/14/2024 at 10:56 AM - BP - 77/46; there was no documentation of reassessment of the vital signs, no reassessment of the patient nor notification of the physician or LIP. On 10/14/2024 at 11:46 AM, Patient #7 was in the dayroom and found to be wheezing, BP - 95/57, HR - 65, R- 17, and T - 99.9. Patient #7 was transferred to the hospital. The “Physician Discharge Order Discharge Plan” reflected that the outcome from his hospitalization was limited due to medical decline. The Behavioral Health Hospital was notified Patient #7 was admitted with pneumonia.”

“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: 49575 Based on facility policy review, document review, medical record review and interview, the hospital failed to provide Registered Nurse (RN) supervision and oversight to evaluate the care provided to the patients and their response to treatment for 4 of 9 (Patient #1, #3, #6 and #7) sampled residents. The findings included: 1. Review of the hospital’s policy, “Patient Observation Guidelines,” last revised 07/2024, revealed “It is the policy of [Hospital #1] to provide a safe and secure environment for patients during their hospitalization... Observation is defined as a level of staff awareness and attention to patient safety/security needs requiring specific protocols and documentation...If a patient’s behavior/mood necessitates a more intensive level of observation, the Charge Nurse may initiate a higher degree of observation upon assessment. The physician/LIP [Licensed Independent Practitioner] is to be notified as soon as possible and an order written. The Charge nurse will notify all staff working with the patient of the observation change...While monitoring hallways and patient care areas, Mental Health Technicians (MHT) ensure patients are not entering rooms not assigned to them...Observe patients...when sleeping by...making sure that the patient has moved from his/her previous sleeping position...Ensure doors that are to be locked are, in fact, locked...” Review of the hospital’s policy “Vital Signs” last revised 11/2023 revealed, “...All patients...will have vital signs taken...as...warranted by patient’s condition. Vital sign include temperature, pulse [heart rate (HR) - number of times the heart beats in a minute; a normal resting HR for a healthy adult is between 60 and 100 beats per minute], respirations, blood pressure [BP - the force of blood pushing against artery walls as the heart pumps blood throughout the body; a normal BP is 120/80], and O2 sat [oxygen saturation - which is the percentage of oxygen in the blood; normal O2 sat for a healthy adult is 95% to 100%]. Vital signs are the responsibility of the nursing staff assigned to the patient. The charge nurse is to be informed of vital signs that are outside of the documented parameters for the facility. The Registered Nurse [RN] on the unit should always use clinical judgement as to whether to contact the medical provider...” Review of the hospital’s policy, “CPR [(Cardiopulmonary Resuscitation) - an emergency procedure that involves chest compressions and mouth-to-mouth breathing used when someone has stopped breathing or the heart has stopped beating]”, last revised 12/2023, revealed “...All CPR certified personnel have the responsibility for initiating emergency resuscitation in the event that it is required, following current American Heart Association Guidelines. The first staff member on the scene has responsibility for: 1. Assessing for responsiveness, gently shake the patient and shouting his/her name. 2. Shouting CODE BLUE [emergency code that indicates a patient is in critical condition and needs immediate medical attention], noting the time. 3. Establishing airway, clearing mouth. 4. Checking carotid pulse, if absent begin external cardiac compression...” 2. Review of the “Patient Admission Information” form dated 8/13/2024, revealed Hospital #1 is “... dedicated to providing a safe environment for its patients and staff...” 3. Review of the “Job Descriptions” for the Charge Nurse, Registered Nurse (RN), Licensed Practical Nurse (LPN), Mental Health Technician (MHT) and Certified Nursing Assistant (CNA), not dated, revealed the staff are to “...adhere to all hospital policies and procedures and report all accidents immediately to their supervisor...have the ability to exercise self-control in potentially volatile situations...Demonstrates knowledge and use of infection control/universal precaution principles to prevent exposure to and transmission of disease...Is slow to respond, therapeutic and thoughtful in response when patients direct anger, frustration, and other extreme emotions directly to you...” 4. Medical record review revealed Patient #1 was transferred from a skilled nursing facility(SNF) and involuntarily admitted to Hospital #1 on 8/13/2024. Patient #1 experienced the following while at Hospital #1: On 8/13/2024, there was no documentation the patient’s O2 sat was monitored for a baseline at the time of admission. (The normal O2 sat for a healthy adult is 95% to 100%). On 8/14/2024 at 11:06 AM - O2 sat - 91%. There was no documentation of a reassessment by a nurse or physician or licensed independent practitioner (LIP) notification of the below normal O2 sat. On 8/15/2024 at 8:10 PM.- O2 sat - 79%; Blood Pressure (BP) -89/53. There was no documentation of a reassessment by a nurse or a physician or LIP notification of the below normal BP or O2 sat. On 8/15/2024 at 8:11 PM - BP - 92/45. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP. On 8/15/2024 at 8:12 PM -O2 sat - 92%; BP - 91/44. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat or BP. On 8/15/2024 at 8:14 PM - O2 sat - 93%; BP - 88/41. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP or O2 sat. On 8/15/2024 at 8:20 PM - O2 sat - 94%. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat. On 8/16/2024 at 7:13 AM - O2 sat - 90%; BP - 87/50. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat and BP. On 8/16/2024 at 7:04 PM - O2 sat - 78%; BP - 151/119; Heart Rate (HR) - 203. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat and the elevated BP. On 8/16/2024 at 10:26 PM - O2 sat - 78%. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat. On 8/17/2024 at 8:00 AM - O2 sat - 84%; BP - 183/110; HR - 157. There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat, elevated BP and HR. On 8/17/2024 at 10:40 AM - BP - 183/110. There was no documentation of a reassessment by a nurse or physician or LIP notification of the elevated BP. Review of the hospital’s “Medical Response Team Documentation” dated 8/17/2024, revealed the Medical Response Team (MRT) was initiated at 5:55 PM and first responders arrived at Hospital #1 at 6:00 PM due to a distress call for Patient #1 and documented. “... Descriptors of events up to time of call: pt [Patient #1] noted to have a congested airway and a cough with difficulty breathing. O2 started per N.P. [Nurse Practitioner] and meds [medications] ordered. Pt got worser [worse] and CPR had to be started... Early Warning Sign...Acute Mental Status Change...Change in LOC [level of consciousness]...Airway Management - ambu bag [handheld device that provides positive pressure ventilation to patients who are not breathing or not breathing adequately]...Additional notes - CPR started... MRT completed call - pt [Patient #1] transferred to [named Hospital] via ambulance... moved to higher level of care...” 5. Medical record review revealed Patient #3 was admitted to Hospital #1 on 7/27/2024 with diagnoses which included Schizoaffective Disorder, Depression, and Other Stimulant Dependence. Patient #3 was voluntarily admitted to the hospital and presented with suicidal ideations with no plan to commit suicide, history of physical and sexual childhood abuse, and a history of domestic violence. Patient #3 reported hearing voices telling her people were out to get her, saw things that were not there, increased anger/irritation, impulsiveness and substance abuse. Patient #3 was assessed as a danger to self and others, poor judgment, poor insight, and poor impulse control. Review of the “Investigation Summary” revealed that on 8/9/2024 at 11:06 PM, revealed that during review of the video footage, Registered Nurse (RN) #4 and MS (Milieu Supervisor) #2 were seen pulling and pushing Patient #3 into the seclusion room so the door could be closed. Patient #3 was in seclusion from 11:06 PM to 2:21 AM, a total of 3 hrs and 15 minutes. 6. Medical Record review for Patient #6’s revealed an admission date of 10/1/2024 with diagnoses that included Vascular Dementia, Behavior Disturbance, Mood Disturbance and Anxiety. Review of vital signs for Patient #6 revealed the following oxygen saturation levels (O2 sats): On 10/2/2024 at 11:19 AM, O2 sat - 89%; There was no documentation of a reassessment by a nurse or physician or Licensed Independent Practitioner (LIP) notification of the below normal O2 sat. On 10/3/2024 at 11:19 AM, O2 sat - 89%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat. On 10/3/2024 at 11:19 AM, O2 sat - 90%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat. Review of the results of a Complete Blood Count (CBC) with Differential (a blood test that measures the number and types of different blood cells in the body) collected 10/8/2024 revealed Patient #6’s white blood count was 2.2 (normal range is 4.0-11.0) and Absolute Neutrophils (this type of white blood cell helps the body fight infection and heal wounds) was 0.0 (normal range is 1.8-7.0). Patient #6 was transferred to an acute care hospital where she was admitted with a diagnosis of Neutropenia (a condition where the absolute neutrophil count is low) and Acute Kidney Injury (a condition that occurs when kidneys suddenly lose their ability to filter waste from the blood, developing within hours or days). 7. Medical Record review for Patient #7 revealed an admission date of 9/25/2024 with diagnoses of Psychosis, History of Hypothyroidism, Cerebrovascular Accident, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Rule Out Early Dementia. Review of Patient #7’s vital signs revealed the following: On 9/27/2024 at 1:03 PM - BP - 89/50; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP. On 9/28/2024 at 11:35 AM - BP - 80/44; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP. On 9/13/2024 at 8:37 AM - BP - 87/54, O2 sat - 92%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP and O2 sat. On 9/13/2024 at 10:48 AM - BP - 85/47, O2 sat - 89%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP and O2 sat.. On 10/12/2024 at 3:55 PM - O2 sat - 93%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat.. On 10/13/2024 at 1:48 PM - O2 sat - 94%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal O2 sat.. On 10/14/2024 at 7:36 AM - BP - 73/47; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP. On 10/14/2024 at 7:39 AM - BP - 73/48; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP. On 10/14/2024 at 7:39 AM - BP - 74/48, O2 sat - 91%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP and O2 sat.. On 10/14/2024 at 7:40 AM - BP - 78/51, O2 sat - 90%; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP and O2 sat. On 10/14/2024 at 10:56 AM - BP - 77/46; There was no documentation of a reassessment by a nurse or physician or LIP notification of the below normal BP. On 10/14/2024 at 11:46 AM, Patient #7 was in the dayroom and found to be wheezing, BP - 95/57, heartrate (HR) - 65, respirations (R)- 17, and temperature (T) - 99.9. Patient #7 was transferred to the hospital. The “Physician Discharge Order Discharge Plan” revealed the outcome from his hospitalization was limited due to medical decline. Patient #7 was admitted to a local hospital with a diagnosis of pneumonia. Refer to A-144”

“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: 33763 Based on policy review, medical record review, and interview, the hospital failed to ensure Nursing Services provided care and services to meet patients’ needs when they failed to assess a patient’s surgical incision site and/or surgical dressing for signs and symptoms of infection and failed to perform wound care per physician’s orders for 1 of 1 (Patient #1) sampled patients admitted with a surgical incision. Nursing Service’s failure to perform wound assessments and failure to provide wound care as ordered, resulted in a wound infection for Patient #1, a 77-year-old male admitted with a surgically closed gunshot wound. The findings included: 1. Review of the hospital’s “Nursing Standards of Care” policy revised 12/2023 revealed, “...Assessment...the nurse will assess the patient in a timely, comprehensive, accurate and systemic manner...The nurse continuously and systematically collects records, and analyzes data that are comprehensive and accurate...” Review of the hospital’s “Skin Integrity, Maintenance of” policy revised 3/2021 revealed, “...The nursing staff will...Monitor for clinical signs of wound infection...” Review of the hospital’s “Wound Care and Irrigation” policy revised 3/2016 revealed, “...When dressings are removed, inspect the wound for any signs of infection...and document the condition of the wound in the nurses’ notes...” 2. Review of the Discharge Summary obtained from Hospital #2 dated 11/23/2023 revealed Patient #1 was admitted to Hospital #2 on 11/21/2023 with a self-inflicted gunshot wound to the left chest/torso region. The patient’s wound was surgically debrided and closed with sutures. The patient was referred to Hospital #1 and was discharged from Hospital #2 with discharge instructions to monitor his incision site for signs and symptoms of infection and to follow up with the surgeon for suture removal in two weeks. The patient had a clean, dry dressing in place upon his hospital discharge. 3. Medical record review revealed Patient #1 was admitted to Hospital #1 on 11/23/2023 with diagnoses of Major Depression. Review of the Nursing Admission Assessment dated 11/23/2023 at 8:30 AM, revealed the patient had a dressing in place on the left chest region. A physician’s order dated 11/24/2023 with an anticipated start date of 11/25/2023 revealed wound care with the application mupirocin (antibiotic) ointment and sterile dressings changes was to be completed two times daily. There was no documentation the wound care was completed from 11/25/2023 through 11/28/2023 and no documentation the patient’s incision site and/or dressing was assessed by nursing staff. A physician’s order dated 11/25/2023 revealed cephalexin, an oral antibiotic, to be administered for 7 days. A physician’s order dated 11/29/2023 revealed mupirocin ointment was ordered to be applied twice daily to the patient’s wound. Although the wound care was documented as completed 11/19/2023 through 12/2/2023, there was no documentation of the condition of the patient’s wound. A physician’s order dated 12/1/2023 revealed ceftrioxone, an injectable antibiotic, was to be given for “...infection...” In an interview on 1/30/2024 at 12:30 PM, the Assistant Chief Nursing Officer verified there was no documentation wound care was completed 11/25/2023 through 11/28/2023 and no documentation of a nursing assessement or description of the patient’s wound. Refer to A-0395”

“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: 33763 Based on policy review, medical record review, and interview, nursing services failed to assess and document a surgical incision site and/or surgical dressing and failed to follow physician’s orders for wound care for 1 of 1 (Patient #1) sampled patients admitted with a surgical incision. The findings included: 1. Review of the hospital’s “Nursing Standards of Care” policy revised 12/2023 revealed, “...Assessment...the nurse will assess the patient in a timely, comprehensive, accurate and systemic manner...The nurse continuously and systematically collects records, and analyzes data that are comprehensive and accurate...” Review of the hospital’s “Skin Integrity, Maintenance of” policy revised 3/2021 revealed, “ Purpose: To maintain and promote healthy skin integrity...The nursing staff will...Monitor for clinical signs of wound infection...” Review of the hospital’s “Wound Care and Irrigation” policy revised 3/2016 revealed, “...Wound care and irrigation shall be performed by a licensed nurse as ordered by the physician to clean the wound and prevent infection...When dressings are removed, inspect the wound for any signs of infection...and document the condition of the wound in the nurses’ notes...” 2. Review of the Discharge Summary obtained from Hospital #2 dated 11/23/2023 revealed Patient #1 “...was admitted after a suicide attempt...he had intended to shoot himself, but the shotgun slipped at the last second. He had a very small pneumothorax...He went to the OR [operating room] with me the day of admission for wound washout and closure. He was ready for discharge shortly after surgery, I contacted the psychiatry team and we coordinated having him admitted inpatient at [named Hospital #1]. At the time of discharge, he was doing very well...plan follow up in about two weeks for suture removal...Hospital Course...Superficial skin injury, small pneumothorax Procedures and Treatment Provided Washout and closure of skin wound, observation...Physical Exam...Integumentary: left lateral chest wound edges well approximated, peri-wound bruising noted, no drainage...Discharge Diagnosis and Plan...Monitor for s/s [signs and symptoms] infection: increased pain, redness, purulent drainage from wound...Gunshot wound of chest...” Review of the nursing assessment completed at Hospital #2 dated 11/23/2023 at 7:15 AM, revealed Patient #1 had a gunshot wound with a surgical incision to his left chest. The assessment further revealed, “...Incision, Wound Dressing Assessment Clean, Dry, Intact...4 x 4’s ABD [army battle dressing, used when high absorbency is required to handle heavy draining wounds or large wounds; also know as abdominal pads] dressing pad, Island dressing [dressing with an absorbent non-adherent central pad surrounded by a breathable adhesive border]...” 3. Medical record review revealed Patient #1 was referred by Hospital #2 and admitted to Hospital #1 on 11/23/2023 following a suicide attempt by a self-inflicted gunshot wound to his chest. The patient’s admitting diagnoses included Major Depression without Psychosis. Review of the Medical Screening Examination dated 11/23/2023 at 4:10 PM, revealed Patient #1 had a “...Hx [history] of recent GSW [gunshot wound] to chest wall...” There was no documentation the dressing was lifted and the incision site was assessed. Review of a Skin Integrity Flowsheet-Assessment or Reassessment dated 11/23/2023 at 6:51 PM, revealed the body drawing of Patient #1 with a circle drawn on the left chest/torso region and described as a “Gun shot wound x [times] 4 days.” Review of the “Nursing Admission Assessment” dated 11/23/2024 at 8:30 PM, revealed Patient #1’s “...Skin Integrity...Gunshot wound covered with dressing on L [left] rib cage...” The assessment further revealed Patient #1 “... presented with a dressing in place to the L thoracic cavity...” Review of the History and Physical Examination dated 11/24/2023 at 9:59 AM revealed Patient #1 was “...s/p [status post] GSW (L) [left] chest, c [symbol for with] pneumothorax and pulmonary contusion...Stable; orders for wound care...” Review of the Daily Nurse Progress Note dated 11/24/2023 at 2:17 PM, revealed “...Skin WNL [within normal limits]...new admit...Dry drsg [dressing] noted to (L) torso intact...” (The skin assessment portion has a box for the nurse place to check mark beside any of the following assessment findings: 1. Alteration in integrity/wound 2. Redness 3. Bruising 4. Odor 5. Superficial Scratches/cuts 6. Diaphoretic 7. Abnormal temperature.) Review of the Daily Nurse Progress Notes dated 11/24/2023 at 8:11 PM, revealed Patient #1’s Skin was “WNL.” There was no documentation the patient’s dressing and/or wound to the left torso was assessed. Review of the Nursing Orders dated 11/24/2023 at 11:42 PM electronically signed by Physician #1 revealed, “Wound Care Left chest surgical-wound-care: mupirocin [antibiotic] ointment BID [two times a day], with sterile dressing changes...Start Time 11/25/23 9:00...” Review of a Physician’s order dated 11/25/2023 at 7:29 AM revealed, “cephalexin [antibiotic] Oral 500 mg [milligrams]...x 7 days Notes: Recent GSW left chest, emergency chest surgery...” Review of the Daily Nurse Progress Notes and the Medication Administration Record (MAR) dated 11/25/2023 through 11/28/2023 revealed no documentation wound care was completed as ordered, no documentation the wound was assessed, and no documentation the surgical dressing was assessed. Review of a physician’s order dated 11/29/2023 revealed, “mupirocin topical 2 % [percent]...Indication: Wound Care notes: 10 days - see wound care order [Nursing Order dated 11/24/2023 above]...” Review of the MAR dated 11/29/2023 through 12/2/2023 revealed the mupirocin ointment was applied twice daily as ordered except for 11/29/2023 at 7:58 PM, when the patient refused. Review of the Daily Nurse Progress Notes dated 11/29/2023 through 12/1/2023 revealed Patient #1’s Skin was “WNL.” There was no documentation Patient #1 had a wound and no documentation of the condition of the patient’s wound. Review of an Ancillary order dated 12/1/2023 at 9:03 AM revealed, “...Medical consult for Management of condition: Incision inflamed and exudate...” Review of a Physician’s order dated 12/1/2023 revealed, “ceftriaxone Injectable 1 g [gram]...Indication: wound infection...Inject IM [intramuscularly] the entire contents of vial...” (Ceftrioxine is an antibiotic used to treat bacterial infections.) Further review of the Daily Nurse Progress Notes dated 12/1/2023 and 12/2/2023 revealed no documentation the Patient #1 had a wound and no documentation of the condition of the patient’s wound. In an interview on 12/30/2023 at 12:30 PM, the Assistant Chief Nursing Officer verified there was no documentation wound care was completed from 11/25/2023 through 11/28/2023 and no nursing documentation and/or description of the patient’s wound. In an interview on 12/30/2023 beginning at 12:35 PM, when asked what should be documented by the nurses on the Daily Nursing Progress Notes skin assessment area, the Chief Executive Officer stated, “that [skin assessment area] just refers to skin turgor, not wounds.” The hospital was unable to provide any further documentation of the patient’s skin/wound status.”