Crestwyn Behavioral Health

“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: 49645 Based on policy review, document review, video recording review, medical record reviews, observation, and interview, the Governing Body failed to ensure patients were provided safe care, used the training techniques learned to provide non-violent interventions and ensure adequate staffing on units to promote care in a safe setting for 7 of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients, 1 of 1 (Patient #6) bedbound patient, and 153 random patients; and failed to follow the hospital’s policy to ensure each unit was safely staffed with sufficient staff to prevent abuse to patients and staff during multiple time periods which totaled 204 calendar days reviewed. The failure to enforce, monitor and ensure adequate staffing to meet the needs of the patients in a safe environment; 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 quality of care and ensure an environment and culture of safety resulted in 8 incidents with 3 patients suffering injuries when the patients did not receive protective care, safe care and preventative care from the hospital. The findings included: 1. Review of the hospital’s job description, “Chief Executive Officer [CEO]” revealed, “... The CEO has primary responsibility for the development, implementation, and achievement of the hospital’s strategic business plan in conjunction with routine operations to include: quality of care, staff development, maintenance of licensure and accreditations, financial performance, and continuous quality improvement... Essential Functions... Manages day-to-day operations and staff so that the hospital achieves its objectives in all of the following key performance areas... effective patient care outcomes ...appropriate fiscal management... maintenance of licensure, accreditation and other regulatory criteria ... implementation of focused business development processes ...medical staff compliance with regulatory and accreditation guidelines... Serves as the final authority for resolution of staff performance concerns and performance improvement activities as appropriate... Guarantee prompt, thorough follow-up of any patient safety issues including system-issue corrections and proactive assessment of high-risk areas... Standard Expectations... Complies with organization policies, procedures, performance improvement initiatives and maintains organizational and industry policies regarding confidentiality... Education/Experience/Skill Requirements... Capable of working within established policies, procedures and practices prescribed by the organization... Supervisory Requirements... Full responsibility for [named hospital] ...” Review of the hospital’s “Chief Nursing Officer [CNO] Job Description” revealed, “ ... Responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing, other departments and the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Collaborates with interdisciplinary treatment teams, other departments and administration to ensure that all residents’ physical, biopsychosocial, age, developmental and cultural needs are met and when they are not met, acknowledges and works to resolve customer complaints. Provide leadership to assure compliance with local, state, and federal regulations, as well as nursing practice standard. Recognizes that patient safety is a top priority... Essential Functions... Anticipates and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed ... Role models expectations related to customer service and demonstrates a sense of urgency related to the importance of patient safety ... Evaluate service needs and staffing requirements to ensure needs of patients are met ...Provide effective staff management (hiring, development, training, performance feedback, etc.) that ensures utilization of personnel to best meet the needs of the patients ... Develop and implement health care related training that assures the best possible delivery of health related supports and services. Review training at least annually and makes modifications as needed ... Intervene in crisis situations and investigate incidents ...” Review of hospital’s policy “Plan for the Provision of Care” effective: 03/2023, revealed, “... Mission, Vision, Values ... [named Hospital] mission is to provide quality, compassionate care for all of the individuals we serve ... Organization: The Governing Board of [named Hospital] has ultimate responsibility and authority for all patient care services provided ... The Board strives to assure that a comparable level of care is provided to patients in all units, areas or departments throughout [named hospital]... The senior management team consists of the Chief Executive Officer (CEO), Medical Director, Chief Nursing Officer (CNO), Director of Risk Management Director of Quality Improvement, Director of Human Resources, and the Chief Financial Officer (CFO) ... The management team functions as the organizational planning body for budget, staffing and programmatic direction and patient care ...Department Directors are accountable for the overall functioning of their departments, especially in the areas of competency, maintaining high standards of ethics, timely performance evaluation, providing appropriate inservice education, adherence to risk management/safety protocols and performance improvement activities ... Care is provided according to an established code of ethical conduct and strict adherence to patient rights...” Review of the Hospital’s Adult Patient Handbook, revealed, “Confidentiality/Patient Rights...If we become aware of any allegations or [of] abuse or neglect, we are required by law to report that information to the [named Department]. We will honor the law in the interest of protecting you and others. We are committed to honoring your rights as a patient during your stay at [named hospital] ... 2. The Governing Body failed to ensure patients’ rights to receive care in a safe setting were promoted when 8 of 12 sampled patients were involved in abuse/neglect/assault situations. One of the 12 patients (Patient #8) was involved in an assault incident and received injuries that were evaluated and treated at an outside hospital. One of the patients (Patient #1) was taken into the courtyard and left in the courtyard without supervision. Patient #1 was away from the hospital and the police found Patient #1 and the patient was returned to the hospital. One patient (Patient #7) was left in the shower without supervision and fell from the wheelchair. The patient stated hit head. The facility’s Incident Log/Reports from from multiple periods of time reviewed from 1/1/2024 through 11/22/2024, representing 204 days, revealed incidents of patient to patient verbal and/or physical assaults; incidents of patient to staff verbal and/or physical assaults; incidents of potential staff to patient abuse; patient falls; and 6 medication variances involving 5 identified patients and 1 unidentified patient: and allegations of patient sexual assault. Refer to A- 057, A-115 and A-144. 3. The Governing Body failed to ensure Nursing Services adhered to hospital policies to protect all current and future vulnerable patients from actual and/or potential harm; failed to ensure the hospital was staffed with an appropriate number of nursing staff to meet the needs of all patients on 204- days reviewed. Refer to A-385 and A-392”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49645 Based on facility document review, policy review, video recording review, medical record review, observation and interview, the facility failed to ensure patients’ rights to be free from verbal and physical abuse by staff were protected; the failure to ensure patients’ received care and services provided in a safe setting for 7 of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients, 1 of 1 (Patient #6) bedbound patients, and 153 random patients; and failed to follow the hospital’s policy to ensure each unit was safely staffed with sufficient staff to prevent abuse to patients and staff during multiple time periods which totaled 204 calendar days reviewed. The hospital failure to ensure care was provided in a safe setting, failed to ensure staff followed all policies to promote the safety of all patients, and failed to ensure the facility was safely staffed placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being. The findings included: Review of the facility’s “Chief Nursing Officer Job [CNO] Description” revealed, “ ... Responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing, other departments and the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Collaborates with interdisciplinary treatment teams, other departments and administration to ensure that all residents’ physical, biopsychosocial, age, developmental and cultural needs are met and when they are not met, acknowledges and works to resolve customer complaints. Provide leadership to assure compliance with local, state, and federal regulations, as well as nursing practice standard. Recognizes that patient safety is a top priority ... Essential Functions ... Anticipates and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed ... Role models expectations related to customer service and demonstrates a sense of urgency related to the importance of patient safety ... Evaluate service needs and staffing requirements to ensure needs of patients are met ...Provide effective staff management (hiring, development, training, performance feedback, etc.) that ensures utilization of personnel to best meet the needs of the patients ... Develop and implement health care related training that assures the best possible delivery of health related supports and services. Review training at least annually and makes modifications as needed ... Intervene in crisis situations and investigate incidents ... Review of hospital’s policy “Plan for the Provision of Care” effective: 03/2023, revealed, “... Mission, Vision, Values ... [named Hospital] mission is to provide quality, compassionate care for all of the individuals we serve ... Organization: The Governing Board of [named Hospital] has ultimate responsibility and authority for all patient care services provided ... The Board strives to assure that a comparable level of care is provided to patients in all units, areas or departments throughout the facility... The senior management team consists of the Chief Executive Officer (CEO), Medical Director, Chief Nursing Officer (CNO), Director of Risk Management Director of Quality Improvement, Director of Human Resources, and the Chief Financial Officer (CFO) ... The management team functions as the organizational planning body for budget, staffing and programmatic direction and patient care ...Department Directors are accountable for the overall functioning of their departments, especially in the areas of competency, maintaining high standards of ethics, timely performance evaluation, providing appropriate inservice education, adherence to risk management/safety protocols and performance improvement activities ... Care is provided according to an established code of ethical conduct and strict adherence to patient rights...” The hospital failed to ensure all vulnerable patients received care and services in a safe setting and remained free of mental and physical abuse to promote quality of care for all patients entrusted in the care of the staff of the Hospital. 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: 49645 Based on policy review, facility document review, video recording review, medical record review, observation and interview, Nursing Services failed to provide adequate oversight and supervision of nursing staff to ensure patients’ needs were met and care was provided in a safe setting for 7 of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients, 1 of 1 (Patient #6) bedbound patient, and 153 random patients; and failed to follow the hospital’s policy to ensure each unit was safely staffed with sufficient staff to prevent abuse to patients and staff during multiple time periods which totaled 204 calendar days reviewed. The failure of Nursing Services to ensure care was provided in a safe setting, failure to ensure staff followed policies to promote the safety of all patients, and failure to ensure the hospital was safely staffed with nursing personnel placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being. The findings included: 1. Review of the hospital’s policy “Staffing Plan for Nursing Services” revealed, “Status: Pending ... The Staffing Plan for Nursing Services reflects specific service needs to meet patient care and organizational needs... The staffing plan outlines requirements as well as contingency plans for unexpected events that may temporarily disrupt staffing in order to sustain safe business operations... Guidelines: The Staffing Plan has been developed to identify staffing needs based on the following criteria: [named Hospital] safe staffing guidelines... patient population... average daily census... length of stay... Specialty needs of patient population served/acuity... physical environment and available technology ... Type of patient care delivered system utilized ... skill mix ...Competencies required ... measurable outcomes of clinical care ... Cross training of personnel and “floating staff” augments staffing and optimizes resources. Utilization of outside agency staff is limited to episodes when other means of staffing have been exhausted. Evaluation is performed within each unit to ensure the skill mix reflects the patient care needs availability of staff, vacancy and budget standards ... In general, the units are staffed 1:5 overall with minimum of 1:14 for Nurses ... The minimum staffing needed for each skill level (RNs, [Registered Nurses] LPNs [Licensed Practical Nurses], Behavioral Health Associates [BHAs], others) is determined by the nurse-patient ratio guidelines and patient care needs of the population ... coverage includes ensuring there is 1 RN on each unit at all times and that there is at minimum 2 staff on each unit at all times..” Review of hospital’s policy “Plan for the Provision of Care,” effective: 03/2023, revealed, “... Mission, Vision, Values ... [named Hospital] mission is to provide quality, compassionate care for all of the individuals we serve ... Nursing Services - Nursing care services are organized under the direction of the CNO [Chief Nursing Officer]...Staffing patterns are determined by a combination of employees per occupied bed ratio (inpatient) and a patient acuity system, with consideration given to individual patient needs in each program...” 2. Review of the hospital’s “Nurse Manager RN Job Description” revealed, “ ...Assist the DON [Director of Nursing]/CNO with directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing for assigned unity. Oversees the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Recognize that patient safety is a top priority...” 3. The hospital failed to provide sufficient staff and adequate oversight and supervision of nursing staff to ensure Patient #1, #7, #8, #9, #10, #11, and #12’s needs were met and a safe, protective environment was provided. The hospital failed to provide sufficient oversight and supervision of nursing staff to ensure Patient #6’s needs were met within a safe, protective environment. The hospital failed to provide sufficient staff and adequate oversight and supervision of nursing staff to ensure 153 Random Patients needs were met in a safe, protective environment. The hospital failed to maintain sufficient staffing on 1 incident days reviewed and 3 observation days of units during the onsite survey. Refer to A-395”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 49645 Based on facility document review, policy review, video recording review, medical record review, observation, and interview, the Chief Executive Officer (CEO) failed to be effective in carrying out the responsibilities for the management of the hospital to ensure ongoing compliance with the Conditions of Participation in order for quality of care to be provided to all patients. The failure of the Chief Executive Officer to carry out the responsibility for the oversight of the conduct of the hospital failure to enforce and monitor the provision of care in a safe setting and the failure to protect the safety and health of the patients and prevent serious outcomes placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well being. The CEO’s failure to manage the hospital’s functions, improve the quality of care and ensure an environment and culture of safety resulted in 7 of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients,1 of 1 (Patient #6) bedbound patient, and 153 random patients not receiving protective care, safe care and preventative care from the hospital. The findings included: 1. Review of the hospital’s job description, “Chief Executive Officer” revealed, “... The CEO has primary responsibility for the development, implementation, and achievement of the hospital’s strategic business plan in conjunction with routine operations to include: quality of care, staff development, maintenance of licensure and accreditations, financial performance, and continuous quality improvement... Essential Functions... Manages day-to-day operations and staff so that the hospital achieves its objectives in all of the following key performance areas... effective patient care outcomes ...appropriate fiscal management... maintenance of licensure, accreditation and other regulatory criteria ... implementation of focused business development processes ...medical staff compliance with regulatory and accreditation guidelines... Serves as the final authority for resolution of staff performance concerns and performance improvement activities as appropriate... Guarantee prompt, thorough follow-up of any patient safety issues including system-issue corrections and proactive assessment of high-risk areas... Standard Expectations... Complies with organization policies, procedures, performance improvement initiatives and maintains organizational and industry policies regarding confidentiality... Education/Experience/Skill Requirements... Capable of working within established policies, procedures and practices prescribed by the organization... Supervisory Requirements... Full responsibility for [named hospital]...” 2. Review of hospital’s policy “Plan for the Provision of Care” effective: 03/2023, revealed, “... Mission, Vision, Values ... [named Hospital] mission is to provide quality, compassionate care for all of the individuals we serve ... Organization: The Governing Board of [named Hospital] has ultimate responsibility and authority for all patient care services provided ... The Board strives to assure that a comparable level of care is provided to patients in all units, areas or departments throughout the named hospital]... The senior management team consists of the Chief Executive Officer, Medical Director, Chief Nursing Officer (CNO), Director of Risk Management, Director of Quality Improvement, Director of Human Resources, and the Chief Financial Officer (CFO) ... The management team functions as the organizational planning body for budget, staffing and programmatic direction and patient care ...Department Directors are accountable for the overall functioning of their departments, especially in the areas of competency, maintaining high standards of ethics, timely performance evaluation, providing appropriate inservice education, adherence to risk management/safety protocols and performance improvement activities ... Care is provided according to an established code of ethical conduct and strict adherence to patient rights...” Review of hospital’s policy “Patient Rights and Responsibilities” revised: 04/2018, revealed, The approval signature by the Governing Board remains pending. The approver is identified as: Chief Executive Officer. The Chief Executive Officer (CEO) for the hospital is identified as the Administrator. “... Patients have the right to be treated with consideration, respect, and full recognition of their dignity and individuality... Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse (including corporal punishment); and from all forms of misappropriation and/or exploitation...” 3. The CEO failed to ensure quality care was provided to the patients who received care from Hospital; failed to ensure the patients received care and services in a safe environment; and failed to carry out the responsibility for the oversight of the conduct of the hospital failure to enforce and monitor the provision of care in a safe setting. a. On 8/31/2024, Patient #12 was involved in an altercation with 5 (unidentified) staff members who grabbed the patient’s arm but the patient snatched it away from the staff. BHA #13 got Patient #12 pinned into a corner near the entrance door and Patient #12 elbowed BHA #13 which caused BHA #13 to lose his footing. Both the patient and the BHA fell to the ground. b. On 9/12/2024, Patient #11 was involved in a verbal altercation with BHA #12 that led to a physical altercation. c. On 10/29/2024, Patient #8 spat on Behavioral Health Associate (BHA) #4. BHA #4 then retaliated and began hitting Patient #8 multiple times in the face resulting in injuries that Patient #8 was transferred to an outside hospital for evaluation and treatment. There was no documentation provided of the name of the hospital Patient #8 was transferred for treatment and evaluation. During an interview on 11/25/2024 at 1:08 PM, the Administrator/CEO stated that the morning after the incident involving BHA #4 and Patient #8 occurred on 10/29/2024, she reviewed the incident report and video footage of the incident. The Administrator confirmed that the unit staff physically abused Patient #8. The Administrator stated she interviewed the unit staff who were present during the incident; and all the unit staff present during the incident were initially suspended during the hospital investigation. The Administrator stated that none of the unit staff present during the incident admitted that any patient abuse by staff occurred. The Administrator stated that BHA #4 denied abusing Patient #8 on 10/29/2024. The Administrator stated that she contacted law enforcement, and police officers from the Police Department #1 came to the hospital and took a report. d. On 11/17/2024, Patients #9 spat on BHA #3. BHA #3 then attacked Patient #9. BHA #3 tried to restrain Patient #9. Patient #10 attacked BHA #3. e. Patient #1 was a patient was on 1:1 (1 qualified staff to 1 high risk patient) precautions due to being on homicide precautions. Patient #1 had threatened to kill local police officers and the local District. On 2/6/2025, Patient #10 was taken out to the courtyard to smoke by BHA #38. There was no other staff or patients present in the courtyard at the time BHA took Patient #1 to the courtyard. BHA #38 left Patient #1 in the courtyard without supervision. Patient #1 climbed the fence and eloped from the facility. f. Patient #7 was a patient who suffered from Postural Orthostatic Tachycardia Syndrome (POTS - a syndrome that affects blood flow and heart rate when you stand up) and Suicide Attempts and Seizures. Patient #7 was 1:1 precautions due to suicidal tendency. On 2/19/2025, Patient #7 was taken to a shower room off the East Unit, placed in a wheelchair accessible chair and left in the shower without supervision. Patient #10 was found about an hour after being left without supervision in the shower and lying on the floor. Patient #10 had an abrasion to her forehead and elbow. During an interview on 2/25/2025 at 2:20 PM, the CNO stated that all hospital units had walk-in showers. The CNO was asked about BHA #102 leaving Patient #7 alone in the shower and Patient #7 falling and hitting her head. The CNO confirmed that BHA #102 left Patient #7 alone in a shower “last Wednesday [2/19/2025] at 8:36 AM” and Patient #7 fell and hit her head. The CNO reported that BHA #102 did not let the other BHAs on the unit know that Patient #7 was left in the shower. The CNO stated that Patient #7 had small abrasions on her forehead and elbow from the fall. Refer to A-144 and A-392 3. The hospital’s Administrator/Chief Executive Officer failed to be responsible and provide the oversight needed to ensure the care and services provided by the hospital’s staff to its vulnerable patient population was done so in a safe environment and ensure the promotion of patients’ rights when multiple incidents of patient-to-patient assault/attacks, patient-to-staff assault/attacks, staff-to-patient abuse, falls, medication variances, and sexual assaults were allowed to occur for the 204 days of incident log/reports reviewed. The facility’s Incident Log/Reports from from multiple periods of time beginning 1/1/2024 and ending 11/22/2024 revealed incidents of verbal and/or physical assaults involving 96 identified patients and an undetermined number of unidentified patients. Review of the facility’s Incident Log/Reports from from multiple periods of time beginning 1/1/2024 and ending 11/22/2024, for a total of 204 days of incident logs/reports reviewed, revealed 49 incidents of verbal and/or physical assaults from 36 patients to an undetermined number of staff. Review of the facility’s Incident Log/Reports from multiple periods of time beginning 1/1/2024 and ending 11/22/2024, for a total of 204 days of incident logs/reports reviewed, revealed 10 incidents of potential staff to patient abuse involving 8 patients and an undetermined number of staff members. Review of the facility’s Incident Log/Reports from multiple periods of time beginning 1/1/2024 and ending 11/22/2024, for a total of 204 days of incident logs/reports reviewed, for a total of 204 days of incident logs/reports reviewed, revealed 31 falls involving 25 patients. Review of the facility’s Incident Log/Reports from multiple periods of time beginning 1/1/2024 and ending 11/22/2024, revealed 6 medication variances involving 5 identified patients and 1 unidentified patient. Review of the facility’s Incident Log/Reports from 1/1/2024 - 3/31/2024 and 8/1/2024 -11/22/2024 (204 calendar days) revealed 9 allegations of sexual assault involving 13 identified patients. Refer to A- 057, A-115 A-144, A-385 and A-392”

“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: 49645 Based on policy review, document review, video recording review, medical record review, observation and interview, the hospital failed to ensure care was provided in a safe setting for seven (7) of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients reviewed, and one (1) of one (1) (Patient #6) bedbound patient, and 153 random patients; failed to ensure staff maintained 1:1 (1 qualified staff member is assigned to 1 high-risk patient) for two (2) of two (2) (Patient #1 and #7) sampled patient; The hospital failed to ensure the hospital was safely staffed with a staff to patient ratio of one (1) staff for every five (5) patients to ensure sufficient staff was available to meet the patient’s needs. The Hospital’s failure to provide care in a safe setting, promote safety by not following order levels of observation and the failure to ensure the hospital was staffed to meet the patient’s individual needs placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being. The findings included: 1. Review of the hospital’s policy, “Patient Rights and Responsibilities” revised: 04/2018 with the approval signature by the Governing Board pending and the approver identified as the Chief Executive Officer (CEO), revealed, “...Patients have the right to be treated with consideration, respect, and full recognition of their dignity and individuality...Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse (including corporal punishment); and from all forms of misappropriation and/or exploitation...Patients have the right to privacy while receiving services...” Review of the hospital’s policy, “Patient Abuse and Neglect” revised 07/2018, with the approval signature by the Governing Board pending and the approver identified as the Chief Executive Officer (CEO), revealed, “... [named Hospital] expects every employee to establish and maintain an appropriate professional, therapeutic relationship with each patient... [named hospital] is committed to the safety and well-being of every patient and there shall be no tolerance for the expression or demonstration by a staff member of inappropriate social and/or sexual behavior toward any patient ... Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. [named Hospital] shall protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members...other patients...All cases of suspected abuse/neglect/exploitation as defined in this policy, whether or not an actual injury has occurred, will be reported and investigated promptly in compliance with state law and regulation...Mental/Psychological Abuse...Acts that inflict emotional harm, invoke fear and/or humiliate, intimidate, degrade, demean or otherwise negatively impact the mental health. Examples include derogatory, threatening, belittling, humiliating, or profane or obscene language toward a patient, physical intimidation...Physical abuse is defined as acts of assault/battery...Examples include assault behavior physically, putting a patient in a seclusion or restraint (lack of freedom) without justification of imminent danger to self or others, pushing, hitting, slapping, or striking a patient...Verbal Abuse...The use of offensive and/or intimidating language that can provoke or upset an individual. Examples include cursing/verbally threatening a patient, cursing/verbally threatening in front of a patient...verbally criticizing a patient... Neglect...Any circumstances which result from leaving unfinished or unattended one’s duties and responsibilities for patient care which endangers a patient’s life or development or impairs the patient’s functioning...Prevention and Training...Orientation and ongoing training of employees on issues related to abuse prohibition practices including definitions of abuse, neglect, exploitation, signs of burnout, reporting allegations, and appropriate interventions to deal with difficult behaviors...Nonviolent Crisis Intervention (CPI) training bi-annually [twice a year typically once every 6 months] to assist staff in understanding and identifying patient abuse, neglect or exploitation...Identifying, correcting and intervening in situations in which abuse, neglect, mistreatment...is more likely to occur... Identification...Identify possible incidents or allegation that need investigation...Any alleged, suspected or witnessed abuse, neglect, exploitation or abandonment by an employee...or caregiver shall be reported to the immediate supervisor as soon as it is known...Notify patient’s physician immediately of any alleged, suspected or witnessed abuse or neglect and suggest physician examines the patient and documents assessment as soon as possible...” Review of the hospital’s policy, “Observations, Patient” with effective date of 11/2022 with the next review date of 11/2023 with approval signature by the Governing Board, revealed, “...In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner...The physician will order one of three levels of observation at time of admission and as the patient’s condition warrants a change...15 minute...Q [every] 5 minute...one-to-one...The physician may also order a precaution level of observation for... suicide... assault... elopement... seizure...fall... sexual acting out...” Review of the hospital’s “Risk Management Incident Reporting Policy” revised 07/2018 with the approval signature by the Governing Board pending and the approver identified as the Chief Executive Officer (CEO), revealed, “ ...The Incident Report is a Risk Management tool that raises awareness of actual or potential exposures to harm... enables the hospital to manage risk, increase safety, and improve the quality of health care provided in the hospital through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan... will help... in identifying and analyzing potential areas of risk and implementing measures to improve the overall quality of care and promote a culture of safety throughout the hospital... Any hospital staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/work day... An “incident” is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety...” 2. Review of the hospital’s Adult Patient Handbook, revealed, Confidentiality/Patient Rights... “ If we become aware of any allegations or [of] abuse or neglect, we are required by law to report that information to the [named Department]. We will honor the law in the interest of protecting you and others. We are committed to honoring your rights as a patient during your stay at [named Hospital] ... Patient Responsibilities ... Speak up if you have any concerns related to safety or feel your rights have been violated in any way ... No violence will be tolerated at [named Hospital]. Violence is any behavior that can be interpreted as dangerous to self, staff, patients, or others. This includes verbal or physical abuse or threats. Staff may encourage you to take a quiet time or a time out if your behavior is becoming unsafe or disruptive to the milieu (the environment in which a patient receives care). Staff may physically hold you to help you regain control if your behavior becomes harmful to yourself or others and you may be escorted to a less stimulating environment so that you may attempt to regain control of yourself ... Safe staffing guidelines ... An RN [Registered Nurse] must always be on the unit. Neither an RN House Supervisor nor an LPN can serve as the RN on that unit ... One staff person cannot be left alone on an inpatient unit ... Minimum of two staff members are scheduled on each unit/area/campus regardless of census ...” Review of the hospital’s “Chief Nursing Officer Job Description [CNO]” revealed, “ ... Responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing, other departments and the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Collaborates with interdisciplinary treatment teams, other departments and administration to ensure that all residents’ physical, biopsychosocial, age, developmental and cultural needs are met and when they are not met, acknowledges and works to resolve customer complaints. Provide leadership to assure compliance with local, state, and federal regulations, as well as nursing practice standard. Recognizes that patient safety is a top priority...Essential Functions... Anticipates and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed ... Role models expectations related to customer service and demonstrates a sense of urgency related to the importance of patient safety ... Evaluate service needs and staffing requirements to ensure needs of patients are met ...Provide effective staff management (hiring, development, training, performance feedback, etc.) that ensures utilization of personnel to best meet the needs of the patients ... Develop and implement health care related training that assures the best possible delivery of health related supports and services. Review training at least annually and makes modifications as needed ... Intervene in crisis situations and investigate incidents ... 3. Medical record review for Patient #12 revealed an admission date of 8/27/2024 with diagnoses that included Schizoaffective Disorder, Bipolar Type, Suicidal Ideations and hearing voices saying to kill yourself. Patient #12 was admitted voluntarily and assigned to the East Unit. On 8/31/2024, Patient #12 began beating on the nursing station window. BHA #13, BHA #8, BHA #9, Licensed Practical Nurse (LPN) #2, and nurse from Agency #1 were unsuccessful in de-escalating Patient #12. The medical record documented an incident on 8/31/2024. The hospital’s summary of the video footage revealed the following: Five (5) staff members surrounded Patient #12, and the staff members attempted to grab Patient #12’s arm, but he snatched his arm away. BHA #13 cornered Patient #12 near the entrance door, and Patient #12 elbowed BHA #13 causing BHA #13 to lose his footing. BHA #13 and Patient #12 then fell to the ground. While attempting to get up from the ground, BHA #13 pulled Patient #12 up by his shirt, and BHA #13 placed his forearm on Patient #12’s neck to pin him to the entrance door of the unit. Patient #12 swung his fist toward BHA #13’s face. BHA #13 placed Patient #12 in a chokehold. LPN #2 administered as needed medication to Patient #12 to calm the patient. 4. Medical record review for Patient #11 revealed an admission date of 9/4/2024 with diagnoses which included Schizoaffective Disorder - Bipolar Type, Auditory Hallucinations and Responding to Internal Stimuli. Patient #11 had an extensive history of mental health treatment and delusional thought processes with anxiety throughout his admission. Review of an Incident Investigation Report dated 10/01/2024 follows: On 9/12/2024, Patient #11 was involved in a verbal altercation with BHA #12 that led to a physical altercation. Patient #11 reported he was “jacked up by staff and pushed to the floor.” On 9/12/2024, Patient #11 was asked by BHA #12 to use hand sanitizer after Patient #11 was observed “playing with his nose”. Patient #11 became aggressive toward BHA #12 and “got in his face, stating, ‘I don’t know who he is’ and that “he had a bad day’.” BHA #12 asked Patient #11 to back up, and when the patient refused, BHA #12 pushed Patient #11 and attempted to escort him back to the unit. Staff Nurse #1 reported walking into the cafeteria and witnessing BHA #12 pushing Patient #11 out of the cafeteria. Patient #11 fell to the ground, and BHA #12 continued to hit Patient #11 several times before staff was able to redirect BHA #12 to walk away. Patient #11 began making threats to other staff. BHA #12 attempted use of verbal de-escalation with Patient #11, but it was not successful. Patient #11 began to yell, “[expletive] you. I will kill you.” BHA #12 immediately attempted the use of handle with care restraints, but Patient #11 was out of control and BHA #12 had no choice but to push Patient #11 out the door. The HRD stated the video footage showed Patient #11 being pushed out of the serving area multiple times into the cafeteria. Patient #11 fell to the ground causing BHA #12 to fall, and they began to scuffle on the floor. 5. Medical record review for Patient #8 revealed an admission date of 10/17/2024 with diagnoses that included Hallucinations and Manic Mood with Psychosis. Patient #8 was placed on 15-minute safety checks. The Patient had a history including physical aggression, medication non-compliance, delusions, auditory and visual hallucinations, labile mood, impulsive behavior, disorganized thought, irritable mood, oppositional/defiant behavior, manic behavior, and sexually inappropriate behavior. Patient #8 was a high risk for suicide and was on Elopement Precautions. The Patient was involuntarily admitted to the Hospital. The Nursing Progress Note dated 10/29/2024, electronically signed by Nurse #5, revealed, “Unprovoked, [Patient #8] entered the day room and hit another patient on the unit. Patient #8 continued to grow more angry, agitated and aggressive towards all patients and staff with no specific target. [Patient #8] began to verbally provoke and physically attack multiple patients on the unit which resulted in physical altercations between multiple patients. The Patient was secluded in the quiet activity room. [named Nurse Practitioner (NP)] #6 was notified. [named NP] #6 advised that the Patient would be discharged the next day (10/30/2024) and gave orders to place the Patient in seclusion”. Patient calmed down after being in seclusion and was later admitted to an acute care hospital after assaulted by a staff member. The patient was discharged due to an acute care hospital. Review of the hospital’s video recording of the assault on 10/29/2024 of Patient #8 revealed the following: At 7:24:50, Behavioral Health Associate (BHA) #4 was seen standing in the doorway. Patient #8 was seen standing in the hallway. Patient #8 and BHA #4 appeared to be talking to each other. At 7:25:27, BHA #4 walked into the hallway toward Patient #8. At 7:26:08, Patient #8 moved toward BHA #4 and attempted to hit at BHA #4. At 7:26:10, BHA #4 walked after Patient #8 and wrestled him to the floor. At 7:26:15, BHA #4 began hitting Patient #8 while the patient was on the floor. At 7:26:20, BHA #5 grabbed Patient #8 and took him to another hallway and held Patient #8 down to the floor. At 7:26:21, BHA #4 went to the hallway where Patient #8 was being held down. BHA #4 began to hit Patient #8 while he was on the floor. An unidentified staff member hit Patient #8. At 7:26:43, Patient #8 ran away and entered a doorway. BHA #4 and other staff followed Patient #8. At 7:27:00, Patient #8 ran out of the doorway into another doorway. At 7:27:07, BHA #4 followed Patient #8 through the doorway and wrestled with Patient #8 while the patient is on the floor. Multiple staff and patients entered the room where BHA #4 and Patient #8 are wrestling. A patient hit Patient #8. At 7:27:29, Multiple staff leave the room while BHA #4 hovers over Patient #8 who was still seen lying on the floor. At 7:27:48, BHA #4 hit Patient #8 in the face multiple times while Patient #8 was lying on the floor. At 7:28:11, BHA #4 exited the room while Patient #8 continues to lay on the floor. BHA #4 exited the room, paces back and forth in the hall before exiting through another door. At 7:28:31, Patient #8 was viewed walking out of the room, until he was out of view of the camera. Review of Nurse #5’s summary of the video footage for the incident that occurred on 10/29/2024 at 7:25 PM revealed: The camera video footage of the alleged physical abuse incident involving Patient #8, BHA #4, BHA #5, BHA #6, BHA #7, Nurse #1, and Nurse #2 was reviewed. The video footage had no audio component. Patient #8 was viewed “swinging at” BHA #4 in front of the nurses station on the East Unit. BHA #4 was then seen actively “going after” Patient #8 and tackling him onto the floor. BHA #5 got Patient #8 up from the floor and took him down the hallway away from BHA #4. BHA #5 held Patient #8 down in the unit hallway. While BHA #5 had Patient #8 held down in the hallway on the East Unit, BHA #4 went to where Patient #8 was being held down by BHA #5 and began attacking and kicking Patient #8. Multiple East Unit patients were seen fighting in a “free for all” situation on the East Unit. Patient #8 was able to get off the floor in the hallway and ran away from BHA #4. Patient #8 was viewed running to the day room and then to the phone room in what appeared to be an attempt to escape from BHA #4. BHA #4 actively pursued Patient #8 into the phone room, and BHA #4 shut the phone room door behind him. Patient #8, BHA #4, and BHA #5 were observed on the camera footage to be shut in the phone room together. BHA #5 was standing beside BHA #4. BHA #4 got on top of Patient #8 and repeatedly hit Patient #8 in the face. BHA #6 was seen on the video footage standing in front of the closed phone room door. No other staff entered the phone room while BHA #6 was standing in front of the closed door. BHA #6 watched BHA #4 repeatedly hit Patient #8 and failed to intervene. BHA #7 was present on the unit when the incident occurred. BHA #7 was viewed leaving the unit. The House Supervisor arrived on the East Unit, BHA #4 got off of Patient #8 and ceased hitting him. The House Supervisor contacted the Chief Nursing Officer and was advised by the Chief Nursing Officer to place Patient #8 in Seclusion for his own safety. Patient #8 was sent to an outside hospital for treatment and evaluation the following morning for surgical treatment of facial/eye injuries. Patient #8 was reported to have significant facial/eye injuries requiring emergency surgical repair. The police report of the assault of Patient #8 from Police Department (PD) #1 dated 10/30/2024 was reviewed. A summary of the police report from PD #1 follows: Police Officer #1 was dispatched to the hospital on 10/30/2024 in response to an alleged assault. The report documented the Chief Executive Officer (CEO) reported that on 10/29/2024 at approximately 7:25 PM, (named BHA #4) was seen to repeatedly punch (named Patient #8). (named Patient #8) sustained injuries and was transported to an outside hospital for emergency surgery. The report documented the CEO stated the injury Patient #8 sustained was an orbital fracture. The report documented Police Officer #1 reviewed the camera footage. The Police Officer documented Patient #8, and BHA #4 had what looked like a “heated conversation” based on their body language. The conversation then led to the patient swinging his right hand in a punching motion at BHA #4’s head. BHA #4 evaded the punch and took Patient #8 to the ground. Patient #8 had several staff members pile on top of him before escaping and running away. BHA #4 pursued Patient #8 down a hallway which was out of view from the camera. Moments later Patient #8 ran back into camera view and into a room with glass windows. BHA #4 was seen entering the room, took Patient #8 to the ground, and repeatedly punched Patient #8 in the face. The Discharge Summary dated 11/5/2024 revealed during hospitalization at the Behavioral Health Hospital, Patient #8 was started on a combination of Risperdal (antipsychotic medication used to treat schizophrenia and bipolar disorder) and Trazadone (medication used to treat depression). The Patient remained psychotic-paranoid and responded to internal stimuli. Patient #8 was sent to an acute care hospital for treatment and evaluation of facial/eye injuries that occurred from an assault on 10/29/2024 as a medical emergency and was admitted to the acute care hospital. The Patient had limited participation in his therapies and remained psychotic at the time of discharge from the Behavioral Health Hospital. Review of the Framework for Root Cause Analysis (RCA) and Corrective Actions of the incident of assault on 10/29/2024 involving Patient #8 was provided by the Risk Manager/Performance Improvement Director. A summary of the RCA follows: On 10/29/2024 at 7:40 PM, Patient #8 was taken to seclusion for safety after initiating a fight with several other patients on East Unit. Patient #8’s diagnosis was Schizophrenia, unspecified. Patient #8’s medications included Risperdal 0.5 milligrams (mg) two times daily (treats Schizophrenia); Trazadone 50 mg at bedtime (treats depression). Patient #8’s Past Medical/Psychiatric History was Schizophrenia, and medication noncompliance. Analysis findings of the Root Cause Analysis (RCA) documented upon video review, it was found the staff did not follow proper Handle With Care ((HWC)- specialized training in verbal, de-escalation, safe, physical management, passive holding methods for aggressive, assaultive challenging behaviors) techniques, including assaulting the patient/aggressor during the altercation on the unit. Staff members who observed the event did not report the event to the supervisor, even when some reported they “heard that a staff member might have hit a patient”. After investigation, it was determined that staff did not follow proper process of HWC techniques, calling a code for more assistance, reporting mishandling of HWC with patients, nurses not assisting staff during altercation, and not immediately assessing the patients after the altercation was resolved. Staff related human performance factors that contributed to the event were listed as: failure to follow established policies/procedures; “intentional” blindness/confirmation bias, possible inappropriate relationships allowing staff to cover for others even if policy is not followed, burnout, unable to control initial emotional response. Nurse on another unit reported difficulty using new phone to call code. Staffing ratios were deemed appropriate at time of incident. The Causal Factors/Root Cause Details were: Many staff that were interviewed did not feel that HWC was done incorrectly at any point during the event. Some staff even reporting that staff member who assaulted patient used “correct” technique without being prompted to describe the technique. All the staff involved in the physical altercation were up to date on the HWC training and Zero Tolerance training. The training methods the staff were up to date on were not implemented by the staff during the 10/29/2024 assault. During an interview on 11/25/2024 at 12:30 PM, the Human Resources Director (HRD) stated she viewed the video footage of that incident. The summary of that review by the HRD follows: Patient #8 and BHA #4 were fighting. The HRD stated that BHA #5, BHA #6, and BHA #7 were present during the fight, and once BHA #4 and named Patient #8 started to fight, a large group of patients (who were not named by the HRD) “jumped in”. BHA #5 picked up the patient to separate him from BHA #4 and took Patient #8 down the hall and restrained him on the floor. BHA #4 went down the hall to where BHA #5 held the patient and kicked and assaulted Patient #8. Patient #8 and BHA #4 started fighting each other again, and the other patients (not named by the HRD) on the unit “jumped in” again and started fighting. Patient #8 ran to the phone room and BHA #4 ran after the patient and closed the door. BHA #7 was at the nurses station and had full view of the incident between BHA #4 and Patient #8. BHA #7 made no attempt to help. Patient #8 was injured during the fight with BHA #4 and suffered an orbital fracture. Patient #8 was sent out to a trauma center for evaluation and treatment. The HRD stated BHA #4 was also injured with a swollen eye and an abrasion on the side of his face. The HRD stated Nurse #5 filled out an incident report that was not accurate and did not match the video footage. The HRD stated that none of the unit technicians tried to stop the assault on (named Patient #8) by BHA #4. Two nurses (unidentified by the HRD) from another unit were present at the time of the incident. A patient (unidentified) told (named Nurse #3) about the incident. The HRD stated (named Nurse #3) did nothing about the incident and didn’t report it. During an interview on 11/25/2024 at 1:08 PM, the Administrator/CEO stated that the morning after the incident involving BHA #4 and Patient #8 occurred on 10/29/2024, she reviewed the incident report and video footage of the incident. The Administrator confirmed that the unit staff physically abused Patient #8. The Administrator stated that she interviewed the unit staff who were present during the incident. The Administrator stated that none of the unit staff present during the incident admitted that any patient abuse by staff occurred. The Administrator stated that BHA #4 denied abusing Patient #8 on 10/29/2024. 6. The following involves the review of Patient #9 and Patient #10 who were involved in a physical altercation with staff: (a) Medical record review for Patient #9 revealed an admission date of 11/6/2024 with diagnoses that included Schizoaffective Disorder, Bipolar Type. Patient #9’s history and physical revealed he had been suicidal for a week, prior to admission, and wanted to jump in front of a car. The Patient had been noncompliant with psychiatric medication for the past month. Patient #9 was referred to the hospital for worsening Psychosis, Visual Hallucinations, Medication Non-Compliance, Paranoia, Depression, Hopelessness, and Suicidal Ideations. The Patient’s medical record documented “multiple recent episodes of aggression towards staff”. Patient #9 was housed on the East Unit of the hospital. (b) Medical record review for Patient #10 was admitted to the Hospital on 10/3/2024 with diagnoses that included Schizoaffective Disorder with Hallucinations, Delusions, Agitation, Anxiety, and Depression, Depression and Suicidal Ideations. Patient #10 was documented to be a danger to himself, others, and/or property, with the need for a controlled environment. Patient #10 reported suicidal thoughts. Patient #10 was housed on the East Unit. (c) Review of video footage of an alleged physical abuse incident that occurred on 11/17/2024 revealed Patient #9 spit on BHA #3 outside the nurses’ station on the East Unit on 11/17/2024. BHA #3 then attempted to physically attack Patient #9. Unit staff restrained BHA #3 from hitting Patient #9 and moved him away from Patient #9. Patient #10 then attempted to hit BHA #3. BHA #3 and Patient #10 began physically fighting. Numerous other patients began fighting and hitting BHA #3. Multiple patients grabbed BHA #3’s hair and were holding him by his hair as the physical altercation continued. Staff who arrived from other units and the two (2) nurses assigned to the East Unit were able to stop the fight and remove the patients’ hands from BHA #3’s hair. (d) Review of the Hospital’s video recording of the assault of Patient #9 revealed the following: At 7:04:00, Patient #9 was viewed pacing on the unit and appeared agitated. At 7:06:25, Patient #9 was viewed to spat on BHA #3. At 7:06:28, BHA #3 attempted to attack Patient #9. BHA #3 was viewed to be restrained by other unit staff and moved away from Patient #9. At 7:06:41, Patient #10 attempted to hit BHA #3. BHA #3 and Patient #10 began to physically fight. The camera footage revealed numerous patients (unidentified) on the unit join in the fight and struck BHA #3 and pulled his hair. Other unit staff (unidentified) tried to stop the fight. At 7:08:19, The fight stopped. BHA #3 was released from the patients who held him by hair. During an interview on 11/25/2024 at 12:30 PM, HRD stated she had viewed the video footage of the incident that occurred on 11/17/2024 between BHA #3, Patient #9, and Patient #10 and a summary follows: The HRD stated Patient #9 was agitated, and BHA #3 approached him and tried to calm him. Patient #9 then spat on BHA #3. The unit nurse (unidentified) immediately intervened and tried to de-escalate the situation, but BHA #3 stepped around the unit nurse and attempted to hit Patient #9. Patient #10 then hit BHA #3, and BHA #3 hit Patient #10 back. Other unit patients (unidentified) began fighting with BHA #3. Another nurse (unidentified) stepped in and tried to control the patients. Several of the patients grabbed BHA #3’s hair. The staff finally got the patients’ hands out of BHA #3’s hair. The House Supervisor was on the unit and tried to calm patients down. It was a very chaotic situation. Once BHA #3 and Patient #10 started fighting, other patients jumped in. The HRD stated she did not know if the patients or BHA #3 were injured. The HRD stated she did not know if anyone reported BHA #3 to the Abuse Registry. 7. Medical record review for Patient #1 revealed an admission date of 2/5/2025 with diagnoses that included Bipolar Disorder, current episode manic severe with psychotic features. Patient #1 remained manic with pressured speech, irritable mood, grandiose delusions and paranoia during his hospital stay. The patient had made several threats to the local police and the District Attorney. The patient was on 1:1 (1 qualified staff to 1 high-risk patient) precautions. While surveyors were onsite on 2/11/2025 at approximately 11:00 AM, unidentified staff reported an incident where a patient (unidentified at the time) was taken out in the courtyard to smoke by (unidentified at the time) Behavioral Health Associate who left the patient outside without any supervision. While the patient was in the courtyard, the patient eloped over the fence and left the hospital property. When the staff returned to get the patient from the courtyard to bring back to the unit, they discovered the patient had eloped. The patient was identified as Patient #1 and the BHA was identified as BHA #38 as the staff who left Patient #1 in the courtyard without supervision. When the surveyors were able to identify the patient that eloped as Patient #1. The surveyors requested to review Patient #1’s medical record. There was no documentation Patient #1 eloped from the hospital on 2/6/2025. The Behavioral hospital’s summary of the camera footage reviewed for 2/6/2025 incident of elopement revealed Patient #1 was taken outside the building into the courtyard by BHA #38. There were no other patients or staff outside in the courtyard at that time. BHA #38 was observed in the camera footage to leave the courtyard and re-entered the building. Patient #1 was left alone in the courtyard. Patient #1 was observed in the camera footage to climb over the courtyard fence and eloped from the hospital. During an interview on 2/25/2025 at 2:20 PM, the Chief Nursing Officer (CNO) stated Patient #1 was very paranoid about the police being out to get him. Incident Report The CNO stated she put Patient #1 on 1:1 precautions before he eloped. When questioned why there was no documentation in Patient #1’s medical record related to him eloping, the CNO stated that nurses get complacent and she was the only one auditing patient medical records. When asked if a Behavioral Health Associate could be assigned a 1:1 observation while also being assigned routine 15 minute checks on other patients, the CNO stated no. The CNO reported that there were no good communication chains at the hospital. 8. Medical record review revealed that Patient #7 was admitted to the hospital with a diagnosis of Major Depressive Disorder, recurrent without Psychotic Features. Patient #7 had a history of Postural Orthostatic Tachycardia Syndrome ((POTS) - a syndrome that affects blood flow and heart rate when you stand up) and Suicide Attempts and Seizures. Patient #7 was 1:1 due to suicidal tendency. Review of the hospital’s investigation review revealed that on 2/19/2025, at 8:50 PM, BHA #102 took Patient #7 via wheelchair to Unit #1, placed her in a shower, and left the shower and Unit #1, leaving Patient #7 unattended. When Patient #7 was found lying in the floor with part of her body still in the shower, Patient #7 stated she had hit her head. There was no documentation neurochecks were performed on the patient to determine any changes that indicated a possible head injury. During a telephone interview on 2/25/2025 at 2:08 PM, RN #5 stated she was working the day that a patient was brought from East Unit to use the shower on the Aspen Unit. RN #5 stated she was not notified that Patient #7 was being brought to her unit to use the shower. RN #5 thought the BHA who brought Patient #7 from the East Unit was staying with that patient while she showered. RN #5 stated she learned later that BHA #102 left the patient unsupervised in the shower. A BHA who worked the Aspen Unit notified RN #5 that Patient #7 was found alone lying on the floor of the shower. RN #5 stated Patient #7 reported that she hit her head and elbow in the shower. RN #5 stated that neurochecks would be done by the staff on the East Unit, but she was not sure if there was a physician’s order for neurochecks. During an interview on 2/25/2025 at 2:20 PM, the CNO stated that all hospital units had walk-in showers. The CNO was asked about BHA #102 leaving Patient #7 alone in the shower, and Patient #7 falling and hitting her head. The CNO confirmed that BHA #102 left Patient #7 alone in a shower “last Wednesday [2/19/2025] at 8:36 AM,” and Patient #7 fell and hit her head. The CNO reported that BHA #102 did not let the other BHAs on the unit know that Patient #7 was left in the shower. The CNO stated that Patient #7 had small abrasions on her forehead and elbow from the fall. During a telephone interview on 2/25/2025 at 2:45 PM, RN #15 stated she was the Charge Nurse on the East Unit on the night that Patient #7 was taken to another unit by BHA #102 for a shower. BHA #102 came to her and told her Patient #7 needed a shower, but she could not use the walk in shower on the unit, because the shower had a “lip” on the shower floor that prevented the wheelchair from entering the shower. Patient #7 was a large lady who required the use of a wheelchair. RN #15 stated she told BHA #102 to take the Patient to the West Unit for a shower, because the unit had wheelchair accessible showers. BHA #102 came back and told RN #15 that the West Unit staff told her that if the patient could not stand up, the patient would not be able to use their shower. BHA #102 said she took the patient to the Aspen unit and was told the patient could use the shower on that unit. RN #15 stated she later got a phone call from the East Unit about an hour after BHA #102 had taken Patient #7 to take a shower. RN #15 was notified that Patient #7 had fallen in the shower. BHA #102 immediately stood up and started running to that unit. RN #15 stated that BHA #102 was not on the unit with Patient #7 when she fell in the shower. RN #15 stated that House Supervisor #1 told her that she (House Supervisor #1) would complete the incident report and began interviewing staff. RN #15 stated House Supervisor #1 told her 3 separate times not to complete an Incident Report. RN #15 stated, “...there have been multiple times I have completed incident reports that have later disappeared.” 9. Medical record review for Patient #6 revealed an admission date of 12/17/2024 with diagnoses that included Anxiety Disorder, Mood Disorder, and Depression Disorder. The patient has a past history of alcohol abuse, anxiety, and depression. Patient #6 was admitted to the hospital from a skilled nursing facility for evaluation and treatment of behaviors. The Patient acted out sexually inappropriate with insulting, vulgar, and crude language towards patients, staff, and other patient’s family members while at the skilled nursing facility. He was unable to attend meals due to his ambulation issues. The Patient was irritable and depressed, and his speech was somewhat mumbled and rambled. The Patient did not really participate in group since the patient was bedridden. During an interview on 2/12/2025 at 12:30 PM, Nurse #10 confirmed that the Behavioral hospital had accepted bedbound patients for admission. The Nurse stated that she had taken care of bedbound Patient #6, who was discharged on 2/10/2025. Nurse #10 stated, “We usually don’t take bedbound patients. This one was a mystery. He was a placement issue and was here about 2 months.” Nurse #10 reported that the staff provided repositioning for that patient, floatation devices for his heels, general monitoring, and looked for skin breakdown. During an interview on 2/12/2025 at 3:00 PM, the CNO confirmed the hospital had accepted a bedbound patient, (named Patient #6) for admission. The patient was there for over a month. She ordered the patient a waffle mattress and “stuff to use to float his heels.” The patient could feed himself and ambulatory abilities were not present. “They had to do so much total care.” The CNO stated Patient #6, “ ... did not really meet the criteria for admission to the facility ...” During a telephone interview on 2/13/2025 at 3:30 PM, the Chief Executive Officer (CEO) stated that Patient #6 was not a bedbound patient, the staff assisted him in transferring to a wheelchair, and he attended groups at the hospital. 10. Review of the facility’s Incident Log/Reports revealed the following: 1/1/2024 - 3/31/2024 and 8/1/2024 -11/22/2024 (204 calendar days) revealed 76 incidents of verbal and/or physical assaults involving 96 identified patients and an undetermined number of unidentified patients as follows: 1/1/2024 - Random Patient #13 reported being assaulted by Random Patient #14 after he reached to help another patient. 1/2/2024 - Random Patient #5 awakened yelling, “why the [expletive] is this [expletive] in my room got [expletive], give the key right now I’m not going to do [expletive]. Random Patient #5 became violent saying he would kill someone. Random Patient #5 was redirected 4 x before running towards Random Patient #15 in attack mode, taking steps back to block any attempts of being hit. Random Patient #5 lunged forward hitting Random Patient #15 on the right side of her face causing the patient to fall to the floor. An ice pack was given for swelling to right side of face. 1/2/2024- Random Patient #140 became upset over the food and Random Patient #16 offered some of her food. Random Patient #140 proceeded to curse Random Patient #16 out. Random Patient #16 got out of her seat and hit Random Patient #140. The two patients were separated. Upon meeting up back on the unit, Random Patient #140 saw Random Patient #16 in the room and proceeded to hit Random Patient #16 and was consequently moved to the North unit. Random Patient #140 and Random Patient #16 both had a knot on their foreheads, but no pain was verbalized. 1/2/2024- While moving Random Patient #17 to another room, Random Patient #18 began talking which agitated Random Patient #17 causing Random Patient #17 to hit Random Patient #18 on the left side of her face several times. 1/5/2024- Random Patient #23 hit Random Patient #22 a few times before being separated by BHA (unidentified). According to Random Patient #23, Random Patient #22 had been picking on him all morning. Random Patient #22 was sent out for medical treatment due to laceration on his right eye. Random Patient #22 did not complaint of pain. Random Patient #22 returned to the facility on 01/05/2025 at 6:06 PM. 1/6/2024- During cigarette break, Random Patient #12 stated she didn’t like black people and Random Patient #23 slapped her in the face causing redness on left side of face. 1/7/2024- Random Patient #25 attacked Random Patient #26 at the nursing station and injured Random Patient #26’s left shoulder. Random Patient #26 was sent to Hospital #3 for possible dislocated shoulder. 1/16/2024- Random Patient #30 was making loud noises and Random Patient #31 approached him telling him to stop. Random Patient #30 became irate and began hitting Random Patient #31 causing the two to fight. Random Patient #30 received an as needed (PRN) medication but continued to talk aggressively to Random Patient #31. Random Patient #31 and Random Patient #32 went into Random Patient #30’s room and fought Random Patient #30. Random Patient #30 had knots on the right side of his head. 1/17/2024- Random Patient #33 reported Random Patient #23 attacked Random Patient #33 in her room. The Police were called and investigated the incident. Random Patient #33 was then transferred to Hospital #4 for medical clearance and returned on 1/18/2024 at 4:30 AM. Nurse Supervisor #4 informed the Risk Manager and the doctor of visible marks around neck area and that the patient reported being kicked in the head. 1/19/2024- Random Patient #34 hit Random Patient #36 in the mouth for mouthing off with another patient. Random Patient #36 had a red, swollen right eye. Random Patient #36 refused any treatment at first, then requested ice. 1/20/2024: Random Patient #35 was in the cafeteria picking with other patients and putting his hands in other patients’ food. The patients began hitting Random Patient #35 in the face and body. (The number and identity of the patients who attacked Random Patient #35 were not documented in the incident log). 1/20/2024: Random Patient #37 punched Random Patient #38 in the face causing the patient to fall to the ground and hit head. Random Patient #37 punched Random Patient #38 for touching him. Random Patient #37 was taken to seclusion. The door was not shut in the seclusion room. Random Patient #37 calmed down was escorted back to the room. 1/22/2024: Random Patient #29 pushed into Random Patient #33 on the way to lunch and pushed Random Patient #33 down to the ground while in the cafeteria. 1/25/2024: Random Patient #39 was walking down the hallway when Random Patient #40 hit Random Patient #39 in the back of the head, after claiming Random Patient #39 spit on him. 1/27/2024: While walking in the hallway, Random Patient #42 walked up to Random Patient #41 and punched Random Patient #41 in the neck unprovoked. 1/27/2024: Random Patient #43 hit Random Patient #19 in the face due to Random Patient #19 brushing against Random Patient #43 in the hallway. Staff quickly intervened and separated the patients. No injuries sustained. 2/3/2024: While in the cafeteria, Random Patient #39 called Random Patient #11 a racial slur and Random Patient #11 slapped Random Patient #39 in the face. 2/3/2024: Random Patient #11 attacked Random Patient #138 with a broomstick and were quickly separated by staff. Random Patient #11 broke two nails on the right hand causing excessive bleeding. 2/3/2024: Random Patient #61 was arguing with Random Patient #85 and staff separated patients. Shortly after, Random Patient #85 hit Random Patient #61 in the face. 2/6/2024: Random Patient #35 was in the room asleep after receiving a PRN med and Random Patient #45 walked down the hall as if he was pacing the hall and walked into Random Patient #35’s room and hit him. 2/7/2024: Random Patient #85 and Random Patient #139 attacked Random Patient #140 while walking down East hallway. staff separated patients. X-ray was ordered due to injury to main party eye. No neurological changes noted. 2/7/2024: Random Patient #100 kicked Random Patient #9 during dinner and Random Patient #9 then hit Random Patient #100 in return. Both patients were separated and returned back to the unit. 2/14/2024: Random Patient #52 was attacked by Random Patient #102 around the nursing station until staff separated the patients. 2/19/2024: Random Patient #105 attacked Random Patient #104, accusing the patient of stealing her drink. Random Patient #105 began yelling and hit Random Patient #104 in the head. 2/20/2024: Random Patient #107 threw water pitcher at Random Patient #108. There were no visible injuries, and the patients did not report any pain. 2/21/2024: Random Patient #108 was knocked over due to a fight between Random Patient #103 and Random Patient #99, resulting in Random Patient #108 breaking her right arm. 2/21/2024: Random Patient #99 was outside on the patio with others during smoke break when Random Patient #99 provoked the other patients. Random Patient #99 walked up to each patient stating wanted to fight and when the patient got close to Random Patient #103, Random Patient #103 punched Random Patient #99. (The number and identity of the other patients involved were not documented in the incident log). 2/22/2024: Random Patient #109 called Random Patient #105 a (expletive) and Random Patient #105 spit on Random Patient #109. 2/23/2024: Random Patient #107 punched Random Patient #52 in the back of the head unprovoked. 2/24/2024: Random Patient #52 was being loud and disturbing the unit. Random Patient #102 came out of the comfort room and pushed Random Patient #52 to the ground. 2/26/2024: Random Patient #111 was observed in the hallway hitting Random Patient #102. Staff quickly intervened and separated patients. Random Patient #102 verbalized safety concerns and Random Patient #111 was moved to a different unit. 2/26/2024: Random Patient #111 was involved in an altercation with a female patient when Random Patient #103 attacked Random Patient #111 multiple times. Once the patients were separated, Random Patient #111 pursued Random Patient #103 causing a second altercation Random Patient #111 was guided off the unit to safety room to de-escalate. (The identity of the female patient was not documented in the incident log). 2/26/2024: Random Patient #112 attacked Random Patient #108 in the dayroom due to Random Patient #108 taking items from the patient’s room. Nurse intervened and separated patients. 2/26/2024: Random Patient #109 was being loud and talking “trash” to other patients when Random Patient #103 asked Random Patient #109 to tone it down. Random Patient #109 made a comment and Random Patient #103 pushed him. (The number and identity of the other patients involved were not documented in the incident log). 2/27/2024: Random Patient #107 accused Random Patient #113 of stealing the patients’ towels then slapped Random Patient #113 across the face. Staff separated the patients. 2/27/2024: Random Patient #115 argued with Random Patient #116 and called Random Patient #116 crazy. Random Patient #115 became upset and slapped Random Patient #116 in the face. Staff intervened and separated patients. 3/7/2024: Patients began fighting on the north unit hallway around 7:45 PM. Staff intervened and separated the patients. No injuries noted. (The number and identity of the other patients involved were not documented in the incident log). 3/8/2024: Random Patient #118 was brought back to the unit after a verbal altercation with another patient. Random Patient #118 claimed water was thrown on Random Patient #118, and Random Patient #118 was waiting on the other patient to arrive back to the unit. Patient was pacing the unit and making threats towards the other patient. (The identity of the other patient involved was not documented in the incident log). 3/12/2024: Random Patient #121 and Random Patient #122 attacked Random Patient #123 as the patient was standing against the wall. 3/15/2024: Random Patient #123 punched Random Patient #127 because Random Patient #127 was threatening staff and physically aggressive. 3/13/2024: Random Patient #124 was responding to internal stimuli when Random Patient #125 walked past, screaming and began to hit Random Patient #124. 3/15/2024: Random Patient #129 woke up screaming (possible nightmare), and Random Patient #128 became upset. The two had words and then started punching each other. 3/17/2024: Random Patient #126 reported that Random Patient #109 swung at her in the hallway at 12:50 AM. The Registered Nurse (RN) (unidentified) heard the patient scream while in the med room drawing up medications. 3/17/2024: Random Patient #121 made threatening statement to Random Patient #123, and Random Patient #123 began to punch Random Patient #121. 3/17/2024: Random Patient #130 became aggressive due to being on unit restriction and unable to smoke. Random Patient #130 knocked out the nursing station glass window and ran outside while others were smoking. Random Patient #125 and Random Patient #131 attempted to escort Random Patient #130 back inside causing code grey (call for assistance for a combative or aggressive patient) to be called. 3/18/2024: Random Patient #118 was yelling and being disruptive to the milieu causing Random Patient #109 to become agitated taking off slides (sandal shoes) and hitting another patient in the head with it. 3/18/2024: Random Patient #125 attacked Random Patient #130 after demanding the remote for the television. 3/19/2024: Random Patient #117 was talking aggressively with staff when Random Patient #109 walked up and punched Random Patient #117 in the face twice. Random Patient #117 then sat down on the floor. 3/19/2024: Random Patient #126 refused to return Random Patient #125’s clothes resulting in a fight between the two parties. Random Patient #125’s mouth was bleeding and Random Patient #126 had a right eye injury. Treatment was offered to both patients, and Random Patient #126 refused. 3/20/2024: The Patient Advocate notified Risk Management that Random Patient #132 reported an altercation with another patient, which was triggered by kitchen staff because they were rooting for the other patient by saying, “she is gonna beat you up.” Random Patient #132 also reported being pushed around by kitchen staff (Kitchen Staff #1 and #2). (The identity of the other patient involved was not documented in the incident log). 3/21/2024: Random Patient #129 hit Random Patient #133 in the face after having a verbal altercation. 3/24/204: Random Patient #136 punched another patient twice in the face and began to make threatening remarks. The other patient fell to the ground. (The identity of the other patient involved was not documented in the incident log). 3/23/2024: Random Patient #136 was choked by Random Patient #135 in his room, and the two began to fight. 3/26/2024: Random Patient #136 and another patient were pacing the unit back and forth when Random Patient #136 started talking aggressively after an exchange of words and began punching other party involved. (The identity of the other patient involved was not documented in the incident log). 8/6/2024: Random Patient #52 was attacked by another patient in the dayroom. (The identity of the other patient involved was not documented in the incident log). 8/7/2024: Random Patient #63 attacked Random Patient #52 in the hallway. The staff separated the patients. 8/7/2024: Random Patient #61 attacked Random Patient #62 in the dayroom. There were no injuries observed, and no pain verbalized by the patients. Staff separated the patients. 8/8/2024: Both patients were pacing the hallway when Random Patient #65 hit Random Patient #66 for no apparent reason. Random Patient #65 hit Random Patient #66 for no apparent reason. Random Patient #65 received an as needed medication. 8/28/2024: Random Patient #73 attacked other party in the medication administration line because the patient was moving too slow. (The identity of the other patient involved was not documented in the incident log). 9/02/2024: Random Patient #74 ran into another patient’s room, jumped in the patient’s bed. The other patient struck Random Patient #74 in the head. Patients were separated. (The identity of the other patient involved was not documented in the incident log). 9/7/2024: Random Patient #78 was confused and entered another patient’s room. That patient became upset and pushed Random Patient #78 which caused the patient (Random Patient #78) to fall down. (The identity of the other patient involved was not documented in the incident log). 9/12/2024: Random Patient #77 took his clothes off and hit another patient because the patient thought Random Patient #77 was about to hit him while both the patients paced in the hallway due to paranoia. (The identity of the other patient involved was not documented in the incident log). 9/14/2024: Random Patient #80 hit another patient in the face. Staff immediately separated patients. (The identity of the other patient involved was not documented in the incident log). 9/16/2024: Random Patient #77 attacked another patient in the hallway. (The identity of the other patient involved was not documented in the incident log). 9/16/2024: Random Patient #89 followed other patients around the unit verbally threatening the staff and other patients. (The number and identity of the other patients involved were not documented in the incident log). 9/17/2024: Random Patient #81 threw coffee on another patient while in the cafeteria for breakfast. (The identity of the other patient involved was not documented in the incident log). 9/17/2024: Random Patient #56 was angry because Random Patient #81 burned another patient in the cafeteria. Random Patient #56 began to yell at Random Patient #81 and hit the patient several times. Staff broke up the fight. (The identity of the other patient involved was not documented in the incident log). 9/18/2024: Random Patient #84 became angry because another patient threatened to kill a staff member, therefore Random Patient #84 began to get in that patient’s face and fight him. (The identity of the other patient involved was not documented in the incident log). 9/19/2024: Random Patient #85 became paranoid and thought another patient was talking to him, therefore Random Patient #85 walked up to that patient, and they began to fight. (The identity of the other patient involved was not documented in the incident log). 9/20/2024: A patient reported was punched in the jaw by the roommate, Random Patient #93. Staff observed Random Patient #93 standing in between the beds. Patients were separated and rooms reassigned. The patient who was struck in the jaw was offered an ice pack, but he refused. (The identity of the other patient involved was not documented in the incident log). 9/20/2024: Random Patient #88 attacked another patient in the phone room. (The identity of the other patient involved was not documented in the incident log). 9/21/2924: Random Patient #88 attacked another patient because Random Patient #88 was called a pervert and antagonized for three days by the other patient. When the other patient said, “Pervert alert” Random Patient #88 began to hit the other patient. The other patient was moved to another unit. (The identity of the other patient involved was not documented in the incident log). 9/23/2024: Random Patient #77 attacked another patient unprovoked. (The identity of the other patient involved was not documented in the incident log). 9/23/2024: Random Patient #87 attacked another patient in retaliation from a prior incident. (The identity of the other patient involved was not documented in the incident log). 9/23/2024: Random Patient #84 attacked another patient in the gym. (The identity of the other patient involved was not documented in the incident log). 9/23/2024: Random Patient #92 was agitated due to another patient yelling. Random Patient #92 attacked the other patient and bit the patient’s finger and left side of the patient’s head. The were separated and first aid rendered. There was no documentation of the name of the other patient. 9/25/2024: Random Patient #92 was calling the African American patients gangsters, thugs and boys which caused hostility on the unit. After Random Patient #92 realized was going to receive a as needed (PRN) medication, Random Patient #92 urinated in the corner of the unit and got naked. Random Patient #85 got angry and hit Random Patient #92. (The number and identity of the African American patients involved were not documented in the incident log). 9/26/2024: Another patient reported Random Patient #94 came into the bathroom and attacked him Random Patient #94 was placed on assault precautions. (The identity of the other patient involved was not documented in the incident log). 10/3/2024: Random Patient #92 became angry and aggressive towards another patient while the other patient played cards. Random Patient #92 hit the other patient in the back of the head. (The identity of the other patient involved was not documented in the incident log). 10/4/2024: Random Patient #97 grabbed another patient’s hair and threw the patient to the ground. (The identity of the other patient involved was not documented in the incident log). 10/4/2024: Random Patient #92 bit another patient in 3 places on the arm. (The identity of the other patient involved was not documented in the incident log). 10/04/2024: Random Patient #92 scratched another patient in the face. (The identity of the other patient involved was not documented in the incident log). 11/8/2024: Another patient called Random Patient #59 names and refused to stop. Random Patient #59 became agitated and threw punches. The other patient threw punches back. (The identity of the other patient involved was not documented in the incident log). 11/17/2024. Random Patient #50 threw hot coffee on another patient’s chest, resulting in burns. Random Patient #50 was placed on unit restriction and separated from peers in order to calm down. (The identity of the other patient involved was not documented in the incident log). 11/11/2024. Random Patient #91 was walking down the hall behind staff yelling at another patient and staff. Random Patient #91 pulled another patient’s hair. They were separated by staff and PRN given. (The identity of the other patient involved was not documented in the incident log). 11/17/2024. Random Patient #58 restrained Random Patient #59 with the hands on the patient’s upper chest/neck area. 11/17/2024. Random Patient #54 asked to be escorted to the restroom. While unlocking the door for Random Patient #54, the patient grabbed the nurse’s hand and the hand of another patient. The nurse broke free from Random Patient #54, but Random Patient #54 ran down the hall continuing to drag the other patient with him. Random Patient #54 was placed in a hold to protect self and other patients safe. (The identity of the other patient involved was not documented in the incident log). 11/17/2024. Entire unit milieu disturbance. There were multiple altercations at once. (The number and identity of the patients involved were not documented in the incident log). 11/17/2024: Random Patient #54 came in comfort room where another patient was laying and touched the patient without consent. The other patient told the BHA (unidentified), and they tried to deescalate the situation, but Random Patient #54 went after the other patient. Random Patient #54 then touched staff and attempted to touch other patients. Random Patient #54 also attempted to fight other patients but was blocked off. (The identity of the other patient involved was not documented in the incident log). 11/19/2024: Random Patient #54 was running around unit and touching patients. He went in dayroom trying to touch patients and Random Patient #55 hit him. They were separated. (The number and identity of the other patients involved were not documented in the incident log). 11. Review of the facility’s Incident Log/Reports from 1/1/2024 - 3/31/2024 and 8/1/2024 -11/22/2024 (204 calendar days) revealed 49 incidents of verbal and/or physical assaults from 36 patients to an undetermined number of staff: 1/03/2024: Random Patient #19 became agitated in group with Therapist and tried fighting with him. Patient was escorted to quiet room and given PRN medication. (The identity of the Therapist was not documented in the incident log). 1/10/2024: Kitchen Staff #1 exited the North station while Random Patient #27 leaned against the door. While exiting, Random Patient #27 pushed against the door and grabbed Kitchen Staff’s leg. Kitchen Staff #1 was bitten in the upper thigh and fell to the ground and went back into the nursing station. 1/27/2024: Random Patient #7 became irate due to not getting Ativan (medication used to manage anxiety). Random Patient #7 yelled and screamed, walked to the nursing station and began hitting the window until it fell out. Random Patient #7 was observed grabbing staff’s arm before knocking out window. There was no documentation of injury. (The identity of the staff member was not documented in the incident log). 1/28/2024: Random Patient #8 was agitated and upset upon arrival and refused to answer questions. Random Patient #8 banged on windows, threatened staff and used racial slurs. Random Patient #8 took chairs and pushed them against the doors in the intake assessment room. The patient also pulled the cover off of the badge scanner and used it as a tool to bang and scrape the window, after continuing to threaten staff and refuse treatment, police was called to help de-escalate the patient and to ensure a safe transfer to the unit. (The number and identity of the staff members threatened by Random Patient #8 were not documented in the incident log). 1/28/2024: Random Patient #10 placed lay on the floor behind the bedroom door which prevented the staff from entering. Random Patient #10 also became physically aggressive towards staff and redirection attempts x 3 were unsuccessful. (The number and identity of the staff members involved were not documented in the incident log). 1/28/2024: Random Patient #44 pushed an Agency BHA to the floor. The patient also punched the Agency BHA with fists while she was on the floor. A code grey was called and the patient was separated from the Agency BHA and the patient was given a PRN medication for his behavior. (The identity of the BHA involved was not documented in the incident log). 1/28/2024: Random Patient #9 was having a psychotic episode when several staff attempted to verbally de-escalate the patient, unsuccessfully. The Patient was verbally and physically threatening to staff. Random Patient #9 received Geodon (antipsychotic medication used to treat acute agitation) 20 milligrams (mg) as per order and remained aggressive and combative and knocked out the window pane at the nursing station. (The number and identity of the staff members involved were not documented in the incident log). 1/30/2024: While attempting to remove tissue that was wrapped around the hand and face, Random Patient #35 launched at staff, was escorted to the room and placed on assault precautions. (The number and identity of the staff members involved were not documented in the incident log). 1/30/2024: Random Patient #6 walked out of the room and began to disrobe and make verbal threats towards staff. Staff redirected the patient and the patient was safety guided to the room. Intramuscular (IM) medication (medication given was not identified in the incident log) given to decrease agitation. (The number and identity of the staff members involved were not documented in the incident log). 2/11/2024: Random Patient #101 climbed onto the nursing station on the ledge yelling, screaming and being assaultive towards staff, unable to redirect. Orders were given for seclusion and restraint and PRN. In the process, staff was injured. Patient was able to get out of the restraint and began to beat her arm on the wall, injuring her wrist. Her wrist was swollen, and a consult was placed for medical evaluation. (The number and identity of the staff members involved were not documented in the incident log. The identity of the female staff who was injured was not documented in the incident log). 2/12/2024: At approximately 7:00 PM, the patient’s spouse made a call to 911 stating Random Patient #101’s arm was broken. Doctor on call was notified and denied patient being taken out by paramedics due to involuntary status and was already seen by a medical doctor on multiple occasions. Random Patient #101 was placed in seclusion and restraint after reportedly punching the windows and walls and making verbal threats towards staff. Random Patient #101 injured her arm further which warranted transfer for non-emergent care at 12:15 AM. (Random Patient #101 had an injury to the arm from prior incident on 02/11/2024 that had been treated by medical staff). The patient returned to the unit at 3:45 AM. Random Patient #101 also made verbal threats of jumping thru the medication room window to hurt staff. The patient punched the medication room window and nursing station window repeatedly, knocking out the windowpane to the nursing window. (The number and identity of the staff members involved were not documented in the incident log). 2/20/2024: Random Patient #106 became physically and verbally aggressive with staff. The Patient attempted to kick the door in the intake and ultimately received a PRN medication at 8:30 PM. (The number and identity of the staff members involved were not documented in the incident log). 2/24/2024: Random Patient #108 was upset when told could not smoke due to unit restriction. Random Patient #108 stood on the table and urinated, started throwing trash from the garbage and verbally threatened the staff. (The number and identity of the staff members involved were not documented in the incident log). 2/27/2024: Random Patient #108 was in the administration hallway with the BHA staff walking from the gym to the unit. Along the way, Random Patient #108 stopped and began beating on the door asking to speak to someone in charge, yelling, stating she wanted to leave. The administration staff intervened to redirect patient which caused more aggression and threatening towards staff. (The number and identity of the staff members involved were not documented in the incident log). 3/5/2024: Random Patient #117 was agitated, and after receiving a PRN the nurse walked the patient to his room. The patient pulled (a female staff) into his room and tried closing the door. The staff member called for help, a code grey was paged, and the patient finally let the staff member go. (The identity of the staff member involved was not documented in the incident log). 3/6/2024: Random Patient #117 attacked Staff #2 by grabbing him towards the head attempting to place him in a head lock. 3/8/2024: Random Patient #119 was mad and irritated about not having a wheelchair. While going to get wheelchair, the patient began smearing feces on the walls and urinated in hallway. Random Patient #119 was verbally aggressive and threatened staff. Random Patient #119 was transferred to another unit. (The number and identity of the staff members involved were not documented in the incident log). 3/13/2024: Random Patient #126 went outside unauthorized during group and ran into the bushes. The patient began pulling sticks from the bushes to use to attack staff. (The number and identity of the staff members involved were not documented in the incident log). 3/13/2024: Random Patient #126 was pacing the hallway when walked up to staff and snatched a mop and trash bag out of staff’s and began hitting the staff until staff pulled the patient away. (The identity of the staff member involved was not documented in the incident log). 3/15/2024: Staff #1 reported to Risk and the HRD that Random Patient #117 was taken off the unit to the seclusion room area to calm him because of disrupting the milieu by screaming. Staff #1 said that the patient and he were in the hallway talking and then the patient pushed him inside the actual seclusion room where he was locked in, and the patient was standing on the opposite side of the door inside of the seclusion room for some seconds until a nurse happened to walk by. This information was not documented on the restraint/seclusion packet from 03/15/2024 or on the incident report. Corrective action provided to staff. 3/18/2024: Random Patient #129 observed verbally threatening to female staff and threatened to kill a BHA. BHA was temporarily removed from milieu for safety. (The identity of the female staff and the BHA involved were not documented in the incident log). 3/19/2024: While trying to guide Random Patient #126 back to her room, the patient became upset and struck the Charge Nurse. (The identity of the Charge Nurse was not documented in the incident log). 3/20/2024: Random Patient #117 became aggressive during breakfast untriggered and attached his leg onto staff member and refused to detach. (The identity of the staff member involved was not documented in the incident log). 3/22/2024: Random Patient #134 aggressively hitting staff member while walking past cafeteria. Staff member was okay to continue 1:1 says patient does not mean any harm. (The identity of the staff member involved was not documented in the incident log). 3/25/2024: Random Patient #129 was aggressive, manic and verbally threatened staff. The Patient walked aggressively towards the nurse while stating, “I will take the shot”, and the patient took off the shirt with a closed fist. Was placed in a therapeutic hold. (The number and identity of the staff members or the nurse involved were not documented in the incident log). 8/1/2024: Random Patient #60 became upset and cursing and spitting on BHA through the window hole. (The identity of the BHA was not documented in the incident log). 8/7/2024: Random Patient #62 got up from the dayroom and punched staff in the face. Patient received a PRN and first aid was offered to the staff. (The identity of the staff member involved was not documented in the incident log). 8/7/2024: Random Patient #62 became upset with staff and attempted to hit the staff. A PRN med was drawn up and when staff attempted to give it, Random Patient #62 fell to the ground to avoid getting the shot. (The identity of the staff member involved was not documented in the incident log). 8/8/2024: Random Patient #67 became irate and verbally aggressive with staff and began swinging and punching the BHA in the face. (The number and identity of the staff members and the BHA involved were not documented in the incident log). 8/14/2024: Random Patient #68 moved from North Unit due to aggressive behavior toward staff and became verbally aggressive with patients. Random Patient #68 was irritated and charged at the staff member. Staff intervened before any punches were thrown. (The identity of the staff member involved was not documented in the incident log). 8/15/2024: Random Patient #69 became verbally aggressive with staff, ripped off toilet seat and swung at staff. The Patient hid a toothbrush in his pants and bent the toothbrush into a weapon. Bedding and clothes taken to search, and patient was placed on phone restriction for threatening to call someone to blow up the place. (The number and identity of the staff members involved were not documented in the incident log). 8/18/2024: Random Patient #67 became very disruptive and aggressive towards staff for being asked to go back to the room. The Patient then threw water in staff member face. (The identity of the staff member involved was not documented in the incident log). 8/29/2024: Random Patient #2 actively threatened the Medical Doctor in consult room, refused to leave room. A Code Grey was called. (The identity of the Medical Doctor was not documented in the incident log). 9/11/2024: Staff attempted to redirect Random Patient #79 as the patient began to get naked on the unit hallway. Random Patient #79 hit staff and would not calm down. Code grey was called to assist patient to seclusion room. (The number and identity of the staff members involved were not documented in the incident log). 9/12/2024: After multiple attempts to redirect Random Patient #82, the patient refused and attacked staff. (The number and identity of the staff members involved were not documented in the incident log). 9/21/2024: Staff walked down the hall when Random Patient #89 grabbed the staff member’s badge and attempted to bite the staff. Other staff intervened. (The identity of the staff member involved was not documented in the incident log). 9/21/2024: While in the gym, Random Patient #69 threatened to kill staff with a colored pencil. (The number and identity of the staff members involved were not documented in the incident log). 9/23/2024: Random Patient #62 spat in the staff’s face after receiving verbal redirection. (The identity of the staff member involved was not documented in the incident log). 10/2/2024: Random Patient #95 was paranoid and combative and used the wheelchair to block the entrance of the dayroom. BHA staff attempted to turn the wheelchair away from the door. Random Patient #95 then grabbed staff by the shirt. This caused the wheelchair to hit the calf of another patient. (The identity of the BHA was not documented in the incident log). 10/4/2024: Random Patient #97 was verbally and physically aggressive. The patient went after staff and pulled the badge off of a nurse. (The number and identity of the staff members or the nurse involved were not documented in the incident log). 10/5/2024: Random Patient #97 asked for seconds in the cafeteria. The staff denied the request, and the patient became upset. Staff attempted to verbally deescalate the patient, but Random Patient #97 attacked the staff member. Random Patient #97 pulled a lock of hair from the Staff’s head and scratched his neck. (The identity of the staff member involved was not documented in the incident log). 11/16/2024: Random Patient #55 was upset about the color of a kickball and stated could not kick it due to the color. Random Patient #55 tried to physically assault the therapist. The patient was escorted back to the unit to calm down. (The identity of the therapist was not documented in the incident log). 11/15/2024: Random Patient #56 attacked the nurse by pushing the nurse in the face and knocking the glasses off. (The identity of the nurse was not documented in the incident log). 11/17/2024: Random Patient #54 physically attacked the RN by grabbing the nurse’s left wrist and pulling on it. Random Patient #59 physically restrained Random Patient #54 causing the patient to release the grip on the RN. (The identity of the RN was not documented in the incident log). 11/17/2024: Random Patient #59 assaulted Staff #11 by pushing the nurse in the face attempting to push through the nurses’ station door. (The identity of the nurse was not documented in the incident log). 11/17/2024: Random Patient #54 was being combative and exhibiting assaultive behavior. Random Patient #54 was destroying hospital property, assaulting staff, charging up and down the hall and other patients, verbal de-escalation was unsuccessful. Random Patient #54 was placed in seclusion. (The number and identity of the staff members involved were not documented in the incident log). 11/17/2024: Risk Management entered on behalf of agency staff. During milieu disturbance, Random Patient #50 attacked RN, pulling on the nurse’s clothes, kicking the nurse multiple times, punching the left side of the nurse’s face causing a busted lip and residual headache. (The identity of the nurse was not documented in the incident log). 11/21/2024: Random Patient #51 was standing in the hallway yelling, and being combative with staff. The patient was held so a PRN could be administered for Random Patient #51 to calm down. (The number and identity of the staff members involved were not documented in the incident log). 11/21/2024: Random Patient #52 hit staff in the back of the head, walked away and removed self from the area. (The identity of the staff member involved was not documented in the incident log). 12. Review of the facility’s Incident Log/Reports from 1/1/2024 - 3/31/2024 and 8/1/2024 -11/22/2024 (204 calendar days) revealed 10 incidents of potential staff to patient abuse involving 8 patients and an undetermined number of staff members: 1/14/2024: Patient #2 reported abuse from staff. While writing statement, nurse mentions flight of ideas present and loose associations. (The identity of the staff member involved was not documented in the incident log). 2/12/2024: While doing vitals, Random Patient #48 told Staff #15 did not know how to do the job and was on Random Patient #48’s time and that the staff was making the finger oxygen reader too tight. They began to exchange words becoming verbally aggressive with each other. Staff #15 was placed on a different unit and eventually suspended pending investigation. 2/28/2024: Random Patient #108 became agitated due to her ride arriving late and began to yell and scream. BHA #35 began to scream back which made Random Patient #108 more agitated. BHA #35 was advised by the nurse to walk away, but instead the BHA kept engaging with the patient and ultimately had to be redirected several times 3/3/2024: Random Patient #114 informed staff members in the dayroom that BHA #2 inflicted harm to the right hand and bruised the bottom side on last night. There was no male tech assigned to the patient last night. The patient was sent out non-emergent. 8/20/2024: Risk Management received report that staff member may have intentionally withheld medications from Random Patient #68. (The identity of the staff member involved was not documented in the incident log). 8/20/2024: Risk Management received report that staff member may have intentionally withheld medications from Random Patient #71. Staff member suspended during investigation. (The identity of the staff member involved was not documented in the incident log). 8/31/2024: Received report from Assistant Director of Nursing (ADON) that staff member was physically aggressive with patient while attempting to de-escalate patient. Staff member suspended pending investigation. (The identity of the staff member involved was not documented in the incident log). 9/12/2024: Random Patient #37 became upset in the cafeteria when staff asked the patient to sanitize hands. Staff was seen pushing Random Patient #37 out of the cafeteria. Staff has been removed from patient care. (The identity of the staff member involved was not documented in the incident log). 10/3/2024: Random Patient #3 became upset, yelling at therapist after not being able to speak with the therapist. It is alleged therapist responded - she would send Random Patient #3 to a shelter. (The identity of the therapist involved was not documented in the incident log). 13. Review of the facility’s Incident Log/Reports from 1/1/2024 - 3/31/2024 and 8/1/2024 -11/22/2024 (204 calendar days) revealed 31 falls involving 25 patients: 1/3/2024: Random Patient #20 stood up from the wheelchair while screaming and fell onto the floor. No injuries or pain reported. 1/4/2024: Random Patient #21 was found on the floor and stated had rolled out of bed when needing to use the restroom. 1/5/2024: Random Patient #21 was sitting on the floor in front of his wheelchair and was asked if fell. The patient responded, “No, I got to go to the bathroom.” Denies hitting head or pain. Staff assisted Random Patient #21 to the bathroom. 1/6/2024: Random Patient #24 had a seizure around 4:40 PM and fell out of the wheelchair and laid on his side. The patient began experiencing chest pain and was sent out to the hospital. 1/8/2024: Random Patient #14 wanted to watch the news and the other patients did not, so the patient fell out of the chair to make a point. 1/10/2024: Random Patient #27 saturated the floors with water, laid down in it and began calling for help. The patient refused all assistance from staff and refused to get up off the floor. 1/10/2024: Random Patient #27 or the patient’s friend called 911 and stated Random Patient #27 had fallen, and no one would help the patient. Patient was sitting in the phone room when Emergency Medical Services (EMS) personnel arrived to transport Random Patient #27 to the hospital despite having no MD order or medical necessity. One of the EMS personnel called his supervisor and reported that the North nurse kidnapped EMS personnel. 1/14/20024: Random Patient #28 was found on the floor by BHA. Patient was disoriented and confused. Appeared to be in no pain. Assessed and no injuries noted, Patient was placed on a high fall risk and Q 5 monitoring. (The identity of the BHA was not documented in the incident log). 1/30/2024: Random Patient #46 yelled from bathroom and was found sitting on the floor beside the bed. Patient stated, “I fell.” Patient blanket was noted to be under the buttock on the floor hanging from the bed and wearing hospital issued slip resistant socks. Assisted patient to the bathroom. 2/15/2024: Patients were outside on the courtyard when the nurse was informed that Random Patient #49 fell to the ground. The patient was conscious, and vitals were stable. No bruising or laceration noted. 2/25/2024: Random Patient #110 slid out of her chair onto the floor in the patient’s room, reporting pain from under the right arm but refused any pain meds. 2/26/2024: Random Patient #141 slipped on water that was leaking from the electrical room. 2/27/2024: Random Patient #114 fell in the bedroom. The patient was found sitting on the floor next to her bed. The patient stated had slipped trying to get to the bathroom. The patient had redness to right side face and buttocks. Increased visual/observation. 3/3/2024: Random Patient #114 fell in the room while trying to go to the restroom and was found lying in the floor on the left side. Right face/head was swollen. The patient was sent out non-emergent for treatment and evaluation. 3/10/2024: Random Patient #120 was walking in the dayroom on the West unit with other patients when the patient fell and was discovered on the floor by staff. 3/10/2024: Approximately 9:40 PM Random Patient #120 was sitting on the floor in front of the wheelchair stating slid out of her chair. “I’m okay help me up.” No injuries noted and denied pain. Patient was re-educated on wheelchair safety and calling for assistance. 3/25/2024: Random Patient #137 lost balance in exam room during safety search and attempted to break fall by reaching for arm and front of shirt. The staff was able to keep the patient from hitting head, but patient did fall on left side and reported hitting the left arm. No injuries observed at time of incident, and no pain verbalized at that time. On 4/2/2024, the Nurse Practitioner was notified due to patient verbalizing pain to left forearm. Orders received for x-ray. 3/31/2024: Random Patient #1 was walking back to the room from the nursing station and then began running, tripped and fell. The patient could not explain why he started running. 8/15/2024: Random Patient #70 fell getting up too fast and tripped over chair. Patient on increased visuals and vitals taken. The following day the patient was sent out to the Emergency Department (ED) for further evaluation as she may have hit her head. The patient returned the same day 4 hours later. (There was no documentation in the incident log to identify which ED Patient #134 was sent to). 8/24/2024: Observed fall. Random Patient #72 reported fell on face, assessed for injury to tooth. Random Patient #72 then reported fell backwards. Staff attempted to assess, and patient accused staff of assault. Staff reiterated to patient the needs to be assessed. Patient had no injuries noted. Patient refused pain medication and assisted to wheelchair. Medical nurse notified. 9/5/2024: Unobserved Fall. Random Patient #75 slipped and fell onto floor from wheelchair. No injuries noted. 9/12/2024: Observed Fall. Random Patient #83 ambulating to breakfast in main hallway and sat down on the floor due to being agitated. 9/14/2024: Observed Fall. Random Patient #76 recently placed in bed by BHA. The BHA walked away, heard a fall, and patient observed laying on the floor. Patient confused and assessed. Vitals taken and no injuries noted. (The identity of the BHA was not documented in the incident log). 9/16/2024. Unobserved fall. Random Patient #86 was lying down in comfort room, and the Patient got up to use the bathroom, stated became dizzy and fell. 10/4/2024. Observed fall. Random Patient #96 was sitting outside during the group and stated was feeling hot and fell backwards off the table. Random Patient #96 was said to be having a seizure. Random Patient #96 stated head is hurting 8/10 (a scale the patient is asked to use to rate pain from 0 - 10, with 0 no pain and 10 the worst pain). Patient #181 hit the back of the head and nurse examined it with no injuries noted. 10/4/2024. Random Patient #98 transferred to ED for fall. (There was no documentation in the incident log to identify which ED Patient #183 was sent to). 11/11/2024: Unobserved Fall. The RN heard a loud noise in the quiet room and found Random Patient #90 on the floor. 11/16/2024: Observed fall. Random Patient #47 raised hand to hit staff and used Handle With Care blocking technique to stop the hit. Due to this, Random Patient #47 fell on the floor. 11/17/2024. Observed Fall. Random Patient #57 had a seizure and fell. The patient hit face/head while falling. Order received for Random Patient #57 to be transported to the Emergency Department. (There was no documentation in the incident log to identify which ED Random Patient #57 was sent to). 11/22/2024: Unobserved fall. Random Patient #53 fell in their room. They received an injury to the foot. 14. Review of the facility’s Incident Log/Reports from 1/1/2024 - 3/31/2024 and 8/1/2024 -11/22/2024 (204 calendar days) revealed 6 medication variances involving 5 identified patients and 1 unidentified patient: 2/1/2024: Random Patient #142. An order was written for Vistaril (antihistamine medication with sedative properties which may be used to treat anxiety and tension) 50 milligrams (mg). Staff #3 saw the order and administered it to the patient. However, the order had already been administered by RN #3, at 10:55 AM. The Nurse Practitioner was notified and made aware and stated it would not harm the patient. The patient had no complaints and no acute distress. 2/4/2024: Staff #4 administered the incorrect dosage of Haldol (antipsychotic medication used to treat schizophrenia). No adverse reactions noted. Breathing is even and unlabored. (The patient and the amount of Haldol administered were not identified in the incident log). 3/10/2024: Staff #6 administered 90 units of Admelog (fast acting insulin) to Random Patient #143. The patient had an order for Novolin 70/30 (combination of short and long acting insulin) - 90 units. NP #5 gave orders to send patient out 911. (There was no documentation in the incident log to identify which ED Random Patient #143 was sent to). 3/16/2024: Medication was omitted from medication received list and resulted in Random Patient #144 being sent to hospital for further evaluation. (There was no documentation in the incident log to identify which ED Random Patient #144 was sent to). 3/23/2024: Random Patient #145 called stating that he received another patient’s medication for someone (Random Patient #96) was told to call back Monday. 8/20/2024: Risk Manager received report that staff member may have intentionally withheld medications from Random Patient #71. Staff member suspended pending investigation. (The identity of the staff member was not documented in the incident log). 15. Review of the facility’s Incident Log/Reports from 1/1/2024 - 3/31/2024 and 8/1/2024 -11/22/2024 (204 calendar days) revealed 9 allegations of sexual assault involving 13 identified patients: 2/5/2024: Random Patient #146 reports waiting on a patient to come out of their room while Random Patient #147 was walking up the hall and asked if he could have a hug. Random Patient #146 said no, and Random Patient #147 grabbed her from the behind and kissed her on the cheek. He let her go and she went behind the nursing station. Random Patient #146 requested a unit change, and she was moved to another unit. 2/7/2024: Random Patient #148 reported Random Patient #99 was sexually inappropriate with her on three different occasions. Random Patient #148 stated that staff was informed. Random Patient #148 filled out a statement, and the statement notes that the patient tried to hug her, grabbed her waist and tried to follow her in the restroom on three separate occasions. Risk manager informed staff during safety huddle that Random Patient #99 had boundary issues and to make sure he is separated from Random Patient #148. Random Patient #99 was also placed on Sexual Acting Out (SAO) precautions. 2/27/2024: Random Patient #108 made an allegation of sexual abuse but did not provide any pertinent information except that it happened last night. 3/7/2024: Random Patient #102’s conservator called facility and spoke with the Chief Nursing Officer alleging sexual intercourse between Random Patient #102 and an unknown male. Time/date of the incident was not provided. There was no other pertinent information provided. 3/24/2024: Nursing staff informed Patient Advocate on 3/25/2024 that Random Patient #149 made sexual allegations against BHA #36 on Sunday between 6:20-6:30 PM. Patient Advocate notified Risk Management on 03/26/2024. Random Patient #149 reported BHA #36 grabbed her butt and said, “I bet you give good head.” He pulled out his penis and told her to suck it, then someone called looking for him. Investigation was started and camera footage was pulled. 8/23/2024: Random Patient #150 approached desk asking to leave Against Medical Advice (AMA) and returned with a letter stating that she’s trapped with no freedom, she is dealing with sexual assault, and that this place is traumatizing. Doctor and Assistant Director of Nursing were notified. Investigation initiated. 8/23/2024: Random Patient #150 wrote a letter to the nurse requesting to leave, stating she was dealing with sexual harassment, being cooped up for long periods of time. She requested to leave because she was at a point of frustration. Random Patient #150 reported in the letter that Random Patient #151 touched her throughout the day in the dayroom and while in line for medication administration. Review of the video footage during morning medication pass revealed no inappropriate behaviors/conduct from either person. 8/30/2024: Random Patient #152 reported that discharged Random Patient #73 sexually assaulted her in the bathroom on the unit hallway. Investigation initiated. 9/24/2024: Random Patient #153 reported that an employee who she named to be Staff #5 came into her room and tried to choke and rape her. She stated this happened during her last admittance at the facility (9/24/24-10/11/2024) 16. During an interview on 2/25/2025 at 1:05 PM, the Director of Risk Management stated, “There are definitely some things at the facility that need to be worked on. Staff are concerned about their safety on the units.” During an interview on 2/25/2025 at 2:30 PM, Nurse Manager 2 stated, “... [named facility] is not a safe environment, There is a lack of staff on the units to support the patient acuity. The units don’t get enough assigned staff. Expectations are unrealistic with what they have to work with at [named facility] ...” The facility failed to ensure its vulnerable patient population received care in an environment that a reasonable person would consider safe. The facility failed to provide emotional health and safety as well as physical safety to the patients’ entrusted to provide the care and services required during their inpatient treatment.”

“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: 49645 Based on hospital’s policy review, document review, medical record review, video recording review, medical record review, observation and interview, the hospital failed to ensure nursing staff was adequate to provide care to meet patients’ needs and nursing provided adequate oversight and supervision to ensure the patients’ needs were met and care was provided in a safe setting for 7 of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients, 1 of 1 (Patient #6) bedbound patient, and 153 random patients; and the hospital failed to maintain sufficient staffing on 1 incident days reviewed and 3 observation days of units during the onsite survey. The findings included: 1. Review of the hospital’s policy “Staffing Plan for Nursing Services” revealed, “Status: Pending ... The Staffing Plan for Nursing Services reflects specific service needs to meet patient care and organizational needs... The staffing plan outlines requirements as well as contingency plans for unexpected events that may temporarily disrupt staffing in order to sustain safe business operations... Guidelines: The Staffing Plan has been developed to identify staffing needs based on the following criteria: [named Hospital] safe staffing guidelines... patient population... average daily census... length of stay... Specialty needs of patient population served/acuity... physical environment and available technology ... Type of patient care delivered system utilized ... skill mix ...Competencies required ... measurable outcomes of clinical care ... Cross training of personnel and “floating staff” augments staffing and optimizes resources. Utilization of outside agency staff is limited to episodes when other means of staffing have been exhausted. Evaluation is performed within each unit to ensure the skill mix reflects the patient care needs availability of staff, vacancy and budget standards ... In general, the units are staffed 1:5 overall with minimum of 1:14 for Nurses ... The minimum staffing needed for each skill level (RNs, [Registered Nurses] LPNs [Licensed Practical Nurses], Behavioral Health Associates [BHAs], others) is determined by the nurse-patient ratio guidelines and patient care needs of the population ... coverage includes ensuring there is 1 RN on each unit at all times and that there is at minimum 2 staff on each unit at all times ... When assigning the patient/staff ratio, the nursing leader (i.e. CNO [Chief Nursing Officer], Nurse Manager, House Supervisor) or designee will consider the abilities and competencies of all nursing staff personnel. The nursing leader or designee will modify the patient/staff ratio as deemed necessary according to the current patient acuity and/or patient volume ... The minimum staffing levels may be adjusted up or down based on workload assessment include patient acuity, staff skill level, and patient care activities including patient education, procedures, volume of admissions, discharges, and transfers ... The goal of staffing each unit is to ensure patient safety in healthcare delivery. Nursing staff are scheduled to provide quality/safe care ... Patient care workload and activities can fluctuate and therefore, requires ongoing assessment and planning to assure that adequate and qualified staff is available to meet patient care needs ... Staffing levels are assessed continuously, and adjustments are made for staff assignments based on the needs of the patient ... The CNO/Nurse Manager/House Supervisor or designee considers the following factors in determining staffing needs ... Patient census and core staffing hours are used to determine staffing needs ... Patient acuity, unit special needs, number of admissions and discharges are factored on a daily basis to ensure all patient needs are met ... A Registered Nurse is always available in the hospital to step in and assume charge duties when needed ... A Registered Nurse plans, assigns, supervises, and evaluates the nursing care of each patient daily ...The unit will be staffed with an adequate number of RNs, LPNs and BHAs to maintain a therapeutic milieu and a safe environment ... When core staffing to census and acuity results in 2 staff on a unit, a plan is in place to provide for meal breaks for personnel to maintain the safe staffing level of an RN and a BHA at all times ... Included in the assessment of staffing is identification of staff that are to respond to emergencies. At all times a minimum of 3 people are to be available to respond to emergencies and/or relieve unit staff on a temporary basis to allow them to respond to the emergency ... Staffing Alternatives to ensure Safe Staffing Guidelines are met ... Identify employees outside of the nursing department that have worked as a nurse or BHA prior to current assignment that are trained to provide direct patient care ... As part of the emergency operations plan, non-nursing staff are to be cross trained upon hire to perform patient care functions i.e. ... observation rounds, vital signs, staff escort, cleaning of environment and may be called upon to assist with providing patient care coverage until addition nursing care staff are available ... If these alternatives are unable to address the staffing needs, the Chief Nursing Officer or designee should be contacted to assist in determining other strategies in coordination with the CEO ... The Nurse Manager should regularly review the clinical sensitive indicators (i.e., patient falls, medication variances and/or patient satisfaction surveys) to evaluate the relationship, if any, to its staffing plan and identify yearly the specific indicators they will be measuring ... Selected performance indicators that fall below threshold shall cur department leaders to evaluate the data, reviewing factors that may have contributed to the occurrences, including staffing patterns, FTE [full time equivalent] allocation, skill mix, etc. If the analysis indicates that a staffing problem exists, Chief Nursing Officer [CNO] in collaboration with CEO [Chief Executive Officer], CFO [Chief Financial Officer], PI [Performance Improvement]/Risk will evaluate the need to adjust staffing levels to meet patient care needs and monitor ...” There was no documentation the “Staffing Plan for Nursing Services” policy of the date the policy was approved. Review of hospital’s policy “Plan for the Provision of Care,” effective: 03/2023, revealed, “... Mission, Vision, Values ... [named Hospital] mission is to provide quality, compassionate care for all of the individuals we serve ... Nursing Services - Nursing care services are organized under the direction of the CNO...Staffing patterns are determined by a combination of employees per occupied bed ratio (inpatient) and a patient acuity system, with consideration given to individual patient needs in each program. A core staff level is determined for each inpatient unit consisting of a charge nurses, mental health technicians, social workers and activity therapist...Adjustments to the core staffing levels are made on the basis of acuity. Such adjustments for planned staffing are made daily by the CNO or designee based on the individual needs of patients ...” Review of the hospital’s “Risk Management Incident Reporting Policy,” revised 07/2018 revealed, “ ... The Incident Report is a Risk Management tool that raises awareness of actual or potential exposures to harm ... enables the hospital to manage risk, increase safety, and improve the quality of health care provided in the hospital through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan ... will help ... in identifying and analyzing potential areas of risk and implementing measures to improve the overall quality of care and promote a culture of safety throughout the hospital...” 2. Review of the hospital’s “Chief Nursing Officer Job Description” revealed, “ ... Responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing, other departments and the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Collaborates with interdisciplinary treatment teams, other departments and administration to ensure that all patients’ physical, biopsychosocial, age, developmental and cultural needs are met and when they are not met, acknowledges and works to resolve customer complaints. Provide leadership to assure compliance with local, state, and federal regulations, as well as nursing practice standard. Recognizes that patient safety is a top priority ... Essential Functions ... Anticipates and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed ... Role models expectations related to customer service and demonstrates a sense of urgency related to the importance of patient safety ... Evaluate service needs and staffing requirements to ensure needs of patients are met ...Provide effective staff management (hiring, development, training, performance feedback, etc.) that ensures utilization of personnel to best meet the needs of the patients ... Develop and implement health care related training that assures the best possible delivery of health related supports and services. Review training at least annually and makes modifications as needed ... Intervene in crisis situations and investigate incidents...” Review of the hospital’s “Nurse Manager RN Job Description” revealed, “ ...Assist the DON [Director of Nursing]/CNO with directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing for assigned unity. Oversees the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Recognize that patient safety is a top priority ...Anticipate and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed... Manage the activities of staff, coordinating safe and appropriate care between departments and disciplines... Manage and evaluate work activities of nursing, technical... Identify the educational needs of others and develop educational or training programs... “ 3. Medical record review for Patient #12 revealed an admission date of 8/27/2024 with diagnoses that included Schizoaffective Disorder, Bipolar Type, Suicidal Ideations and hearing voices saying to kill yourself. Patient #12 was admitted voluntarily and assigned to the East Unit. On 8/31/2024, Patient #12 began beating on the nursing station window. BHA #13, BHA #8, BHA #9, Licensed Practical Nurse (LPN) #2, and nurse from Agency #1 were unsuccessful in de-escalating Patient #12. The medical record documented an incident on 8/31/2024. The hospital’s summary of the video footage revealed the following: 5 staff members (unidentified) surrounded Patient #12, and the staff members attempted to grab Patient #12’s arm, but he snatched his arm away. BHA #13 cornered Patient #12 near the entrance door, and Patient #12 elbowed BHA #13 causing BHA #13 to lose his footing. BHA #13 and Patient #12 then fell to the ground. While attempting to get up from the ground, BHA #13 pulled Patient #12 up by his shirt, and BHA #13 placed his forearm on Patient #12’s neck to pin him to the entrance door of the unit. Patient #12 swung his fist toward BHA #13’s face. BHA #13 placed Patient #12 in a chokehold. LPN #2 administered as needed medication to Patient #12 to calm the patient. 4. Medical record review for Patient #11 revealed an admission date of 9/4/2024 with diagnoses which included Schizoaffective Disorder - Bipolar Type, Auditory Hallucinations and Responding to Internal Stimuli. Patient #11 had an extensive history of mental health treatment and delusional thought processes with anxiety throughout his admission. Review of an Incident Investigation Report dated 10/01/2024 follows: On 9/12/2024, Patient #11 was involved in a verbal altercation with BHA #12 that led to a physical altercation. Patient #11 reported he was “jacked up by staff and pushed to the floor.” On 9/12/2024, Patient #11 was asked by BHA #12 to use hand sanitizer after Patient #11 was observed “playing with his nose”. Patient #11 became aggressive toward BHA #12 and “got in his face, stating, ‘I don’t know who he is’ and that “he had a bad day’.” BHA #12 asked Patient #11 to back up, and when the patient refused, BHA #12 pushed Patient #11 and attempted to escort him back to the unit. Staff Nurse #1 reported walking into the cafeteria and witnessing BHA #12 pushing Patient #11 out of the cafeteria. Patient #11 fell to the ground, and BHA #12 continued to hit Patient #11 several times before staff was able to redirect BHA #12 to walk away. Patient #11 began making threats to other staff. BHA #12 attempted use of verbal de-escalation with Patient #11, but it was not successful. Patient #11 began to yell, “[expletive] you. I will kill you.” 5. Medical record review for Patient #8 revealed an admission date of 10/17/2024 with diagnoses that included: Hallucinations, Manic Mood with Psychosis, He was an involuntary admission. He was placed on 15-minute safety checks. The patient had a history including physical aggression, medication non-compliance, delusions, auditory and visual hallucinations, labile mood, impulsive behavior, disorganized thought, irritable mood, oppositional/defiant behavior, manic behavior, and sexually inappropriate behavior. Patient #8 was a high risk for suicide and was on Elopement Precautions. Review of the hospital’s video recording of the assault on 10/29/2024 of Patient #8 revealed the following: At 7:24:50, Behavioral Health Associate (BHA) #4 was seen standing in the doorway. Patient #8 was seen standing in the hallway. Patient #8 and BHA #4 appeared to be talking to each other. At 7:25:27, BHA #4 walked into the hallway toward Patient #8. At 7:26:08, Patient #8 moved toward BHA #4 and attempted to hit at BHA #4. At 7:26:10, BHA #4 walked after Patient #8 and wrestled him to the floor. At 7:26:15, BHA #4 began hitting Patient #8 while the patient was on the floor. At 7:26:20, BHA #5 grabbed Patient #8 and took him to another hallway and held Patient #8 down to the floor. At 7:26:21, BHA #4 went to the hallway where Patient #8 was being held down. BHA #4 began to hit Patient #8 while he was on the floor. An unidentified staff member hit Patient #8. At 7:26:43, Patient #8 ran away and entered a doorway. BHA #4 and other staff followed Patient #8. At 7:27:00, Patient #8 ran out of the doorway into another doorway. At 7:27:07, BHA #4 followed Patient #8 through the doorway and wrestled with Patient #8 while the patient is on the floor. Multiple staff and patients entered the room where BHA #4 and Patient #8 are wrestling. A patient hit Patient #8. At 7:27:29, Multiple staff leave the room while BHA #4 hovers over Patient #8 who was still seen lying on the floor. At 7:27:48, BHA #4 hit Patient #8 in the face multiple times while Patient #8 was lying on the floor. At 7:28:11, BHA #4 exited the room while Patient #8 continues to lay on the floor. BHA #4 exited the room, paces back and forth in the hall before exiting through another door. At 7:28:31, Patient #8 was viewed walking out of the room, until he was out of view of the camera. 6. Medical record review for Patient #9 revealed an admission date of 11/6/2024 with diagnoses that included Schizoaffective Disorder, Bipolar Type. Patient #9’s history and physical revealed he had been suicidal for a week, prior to admission, and wanted to jump in front of a car. He had been noncompliant with psychiatric medication for the past month. Patient #9 was referred to the hospital for worsening Psychosis, Visual Hallucinations, Medication Non-Compliance, Paranoia, Depression, Hopelessness, and Suicidal Ideations. The patient’s medical record documented “multiple recent episodes of aggression towards staff”. Patient #9 was housed on the East Unit of the hospital. Medical record review for Patient #10 was admitted to the Hospital on 10/3/2024 with diagnoses that included Schizoaffective Disorder with Hallucinations, Delusions, Agitation, Anxiety, and Depression, Depression and Suicidal Ideations. Patient #10 was documented to be a danger to himself, others, and/or property, with the need for a controlled environment. Patient #10 reported suicidal thoughts. Patient #10 was housed on the East Unit. Review of the Hospital’s video recording of the assault of Patient #9 revealed the following: At 7:04:00, Patient #9 was viewed pacing on the unit and appeared agitated. At 7:06:25, Patient #9 was viewed to spat on BHA #3. At 7:06:28, BHA #3 attempted to attack Patient #9. BHA #3 was viewed to be restrained by other unit staff and moved away from Patient #9. At 7:06:41, Patient #10 attempted to hit BHA #3. BHA #3 and Patient #10 began to physically fight. The camera footage revealed numerous patients (unidentified) on the unit join in the fight and struck BHA #3 and pulled his hair. Other unit staff (unidentified) tried to stop the fight. At 7:08:19, The fight stopped. BHA #3 was released from the patients who held him by hair. 7. Medical record review for Patient #1 revealed an admission date of 2/5/2025 with diagnoses that included Bipolar Disorder, current episode manic severe with psychotic features. Patient #1 remained manic with pressured speech, irritable mood, grandiose delusions and paranoia during his hospital stay. The patient had made several threats to the local police and the District Attorney. The patient was on 1:1 [1 qualified staff to 1 high-risk patient] precautions. The hospital’s summary of the camera footage reviewed for 2/6/2025 incident of elopement revealed Patient #1 was taken outside the building into the courtyard by BHA #38. There were no other patients or staff outside in the courtyard at that time. BHA #38 was observed in the camera footage to leave the courtyard and re-entered the building. Patient #1 was left alone in the courtyard. Patient #1 was observed in the camera footage to climb over the courtyard fence and eloped from the hospital. 8. Medical record review revealed that Patient #7 was admitted to the hospital with a diagnosis of Major Depressive Disorder, recurrent without Psychotic Features. Patient #7 had a history of Postural Orthostatic Tachycardia Syndrome (POTS - a syndrome that affects blood flow and heart rate when you stand up) and Suicide Attempts and Seizures. Patient #7 was 1:1 due to suicidal tendency. Review of the hospital’s investigation review revealed that on 2/19/2025, at 8:50 PM, BHA #102 took Patient #7 via wheelchair to Unit #1, placed her in a shower, and left the shower and Unit #1, leaving Patient #7 unattended. When Patient #7 was found lying in the floor with part of her body still in the shower, Patient #7 stated she had hit her head. There was no documentation neurochecks were performed on the patient to determine any changes that indicated a possible head injury. The hospital failed to provide sufficient staff and adequate oversight and supervision of nursing staff to ensure Patient #1, #7, #8, #9, #10, #11, and #12’s needs were met and a safe, protective environment was provided. 9. Medical record review for Patient #6 revealed an admission date of 12/17/2024 with diagnoses that included Anxiety Disorder, Mood Disorder, and Depression Disorder. The patient has a past history of alcohol abuse, anxiety, and depression. Patient #6 was admitted to the hospital from a skilled nursing facility for evaluation and treatment of behaviors. The Patient acted out sexually inappropriate with insulting, vulgar, and crude language towards patients, staff, and other patient’s family members while at the skilled nursing facility. He was unable to attend meals due to his ambulation issues. The Patient was irritable and depressed, and his speech was somewhat mumbled and rambled. The Patient did not participate in group since he was bedbound. During an interview on 2/12/2025 at 12:30 PM, Nurse #10 stated, “We usually don’t take bedbound patients. This one was a mystery. He was a placement issue and was here about 2 months.” Nurse #10 staff had to provide maximum care for the patient, including feeding, dressing, grooming, toileting, turning and repositioning to prevent skin breakdown and other complications of decreased mobility. The hospital failed to provide sufficient oversight and supervision of nursing staff to ensure Patient #6’s needs were met within a safe, protective environment. 10. Review of the facility’s Incident Log/Reports from 1/1/2024 - 3/31/2024 and 8/1/2024 -11/22/2024 (a total of 204 calendar days) revealed: a. 76 incidents of verbal and/or physical assaults involving 96 identified patients and an undetermined number of unidentified patients. b. 49 incidents of verbal and/or physical assaults from 36 patients to an undetermined number of staff. c. 10 incidents of potential staff to patient abuse involving 8 patients and an undetermined number of staff members. d. 31 falls involving 25 patients. e. 6 medication variances involving 5 identified patients and 1 unidentified patient. f. allegations of sexual assault involving 13 identified patients. 11. Observations during a tour of the patient units accompanied by House Supervisor #1 on 12/10/2024 at 7:30 PM, revealed the following: a. Unit 1 had a current census of 12 patients. It was staffed with 1 nurse and 1 BHA. The nurse on the unit was unable to tell the Surveyor how many patients were currently on any type of ordered precautions. A second nurse on the unit was identified as being in orientation. House Supervisor #1 stated that staff in orientation were not counted in the staffing ratio. All patients on the unit were on 15-minute checks by staff. b. Unit 2 had a current census of 15 patients. The unit was staffed with 1 RN, 1 LPN, and 2 BHAs. All patients were on 15-minute observations. Unit staff was unable to identify to the Surveyor if any of the patients were on any type of ordered precautions. c. Unit 3 had a current census of 19 patients. The unit was staffed with 1 RN, 1 LPN, and 2 BHA. A third nurse, identified as in orientation, was present on the unit. Nurse #6 identified the following observations/precautions in addition to the 15-minute checks required for all patients. 1 patient was on Continuous Positive Airway Pressure (CPAP - a machine worn by a person who has sleep apnea or other sleep related breathing issues; it delivers constant air pressure to keep the airway open during sleep); 8 patients on suicide precautions; 2 patients on elopement precautions; 1 patient on Sexual Acting Out precautions; 1 patient on fall precautions. During an interview on 12/10/2024 at 7:55 PM, Nurse #6 stated, “Generally every patient on that unit [Unit 3] is on some type of precautions.” d. Unit 4 had a current census of 18. There were 2 nurses present on the unit and 2 BHAs were assigned to that unit, but 1 of those BHAs was in orientation and could not be counted in the staffing ratio. That resulted in 2 nurses and 1 BHA as unit staff. In addition to the routine monitoring of all patients every 15 minutes, the following precautions were identified on the unit: 1 patient on fall precautions; 5 patients on suicide precautions; 1 patient on elopement precautions; 1 patient on homicide precautions; 3 patients on the unit were under the age of 21. 12. Observations during a tour of the patient units on 2/12/2024 at 12:30 PM, revealed the revealed the unit census at that time was 19. The unit was staffed with 2 RNs and 2 BHAs. The patients were on the following precautions: 2 patients on elopement precautions; 8 patients were on suicide precautions, 6 patients were on fall precautions, 1 patient was on assault precautions, 1 patient was on seizure precautions. During an interview on 2/12/2025 at 12:40 PM, Nurse #11 stated there are times when they don’t have enough staff. Nurses and techs assigned to the unit sometimes get pulled to other units, leaving West Unit short of staff. 13. Observations during a tour of the patient units on 2/25/202 at 12:30 PM, revealed the following: a. West/Geropsychiatric Unit on 2/25/2025 at 12:00 PM revealed the census was 19. RN #7 was the Charge Nurse for the West Unit on 2/25/2025. House Supervisor #1 was the Medication Nurse on 2/25/2025. There were 3 BHAs working on the unit that day. 1 patient was a 1:1 observation for high fall risk and was also very combative. There were 3 patients who require assistance with Activities of Daily Living (ADLs) on the unit, and 3 patients, ambulatory by wheelchair, require assistance of staff for toileting needs. During an interview on 2/25/2025 at 12:10 PM, RN #7 stated the unit was not adequately staffed and more BHAs were needed on the unit. She stated she made unit rounds every hour. The BHAs make unit rounds every 15 minutes. b. South Unit on 2/25/2025 at 12:20 PM revealed the unit census was currently 20. RN #8 worked as the medication nurse that shift. There were initially 2 BHAs assigned to the unit but 1 of those BHAs left at 11:30 AM (scheduled leave). There was currently only 1 BHA on the unit. RN #9 was currently doing the charting and RN #10 had to go with the patients to group. During an interview on 2/25/2025 at 12:30 PM, when RN #8 was asked if she has ever been instructed by hospital leadership staff not to document an incident, RN #8 did not directly answer that question. She stated, “Things come up missing from Incident Reports.” Last week, Corporate Office was here, a BHA dragged a patient by her ankles from behind the Nurses Station, the Chief Nursing Officer took up for the BHA, and the paperwork related to that incident was ‘lost’. The Incident Report “came up missing.” RN #8 stated during that interview that the new Chief Nursing Officer is “terrible, awful.” RN #8 stated that staff bring complaints to Management but those complaints are overlooked. RN #8 described staff morale as “down the drain”. RN #8 stated that leadership staff are hard to reach and don’t answer calls. c. Observations on the Aspen Unit on 2/25/2025 at 12:40 PM revealed the patient census was 17. One patient was on detoxification (detox - withdrawal from alcohol) precautions. The unit was staffed with 2 RN’s, and 1 BHA. 14. During a telephone interview on 12/5/2024 at 11:00 AM, the CNO stated that in general the staffing on the units was not sufficient. The CNO stated actual staff working on specific days/shifts does not match with what is shown on the staffing schedule. The CNO stated there were multiple problems with unit staffing including 3 people had access to change the staffing schedule, staff might not go to the unit they were assigned, and there had been no staff accountability for problems such as call-ins and tardiness. The CNO stated, “There has been zero accountability and staff gets by with anything they want to... the lack of accountability by staff is absolutely ridiculous...” The CNO stated Administration knows there needed to be change in the structure at the hospital. During a telephone interview on 12/6/2024 at 1:10 PM, the Assistant Director of Nursing stated the Staffing Coordinator (who was a Certified Nursing Assistant) made the staffing schedule. The Staffing Coordinator and the CNO go over the staffing schedule. When there was a different number of staff working on the unit as opposed to the number of staff the staffing schedule showed as working on the unit, the unit nurse was supposed to notify the scheduler. Attempts are then made to get additional staff utilizing (named Agency #1) and also by direct calls made to staff to see if they are willing to come in to work. During an interview on 2/12/2025 at 3:00 PM, the CNO reported Nursing leadership steps in to be sure staffing was not short. The hospital was now considering 1:1 observations/precautions when they do the unit staffing. There “probably” had been times when all the unit staff were all agency staff. The CNO stated the staffing schedule should match the staff who were working the unit, and unit staffing was checked every shift. During an interview on 2/25/2025 at 2:30 PM, Nurse Manager #2 stated the staff assignment sheets did not match actual unit staff; and the staffing schedule was padded to appear as if there are more staff working the units that the actual staff working the units. Last weekend was Nurse Manager #2’s weekend to work (2/22/2025 and 2/23/2025). The Nurse Manager #2 stated, “It was a ghost town There was not enough staff. No one would answer the telephone but me.” The Nurse Manager #2 stated the hospital is not a safe environment, and there is a lack of staff on the units to support the patient acuity. The Nurse Manager stated the units did not get enough assigned staff. The Nurse Manager #2 stated that Expectations are unrealistic with what they have to work with at the hospital. The Nurse Manager stated the Staff feels patient acuity is too high. 16. An unsigned electronic mail was received on 2/23/2025 at 9:15 PM that documented the following: The Sender reported observations of staffing schedules that appeared to be padded; he/she came in to find staff names on the schedule, yet the staffing was frequently out of ratio. Names of staff who had called in remained on the schedule, creating a misleading representation of available staff. Despite having a staffing coordinator in place, the hospital continued to experience significant gaps in staffing which raised serious concerns regarding the safety and well-being of the patients. An unsigned electronic mail was received on 2/26/2025 at 8:01 AM that documented staffing is way out of ratio. Copies of SuperView (time system utilized by (named hospital)) were attached to that e-mail. An unsigned electronic mail was received on 2/25/2025 at 6:39 AM that documented an encounter of 1 BHA to 20+ patients. The e-mail also reported a patient who tried to elope from his assigned unit via the ceiling/roof on the Aspen Unit was not placed on 1:1 precautions and unit restrictions. That patient was brought to another unit by the nurse manager and the unit BHA was instructed to “take out for a smoke”. That BHA was the only working staff on the floor. The BHA did as he was instructed and returned into the building to complete assigned task of checks on other patients. At no time was alternate/on clock BHA/nurses directed to assist or relieve that BHA. At the point of going back out (to where the patient was left to smoke) BHA noted the patient climbing the fence. That BHA attempted to push the panic button but the system did not work, The BHA yelled for assistance and proceeded after the patient. The hospital failed to ensure oversight and supervision to monitor for changes in the patient population based on the changing patient needs to ensure adequate staffing to promote patients’ safety and health and provide the care and services required by the patient to promote health and safety. Refer to A-144”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 33763 Based on policy review, medical record review and interview, the facility failed to ensure post-acute care plans were arranged and agreed upon by the patient and/or family members upon discharge for 1 of 3 (Patient #1) sampled discharged patients. The findings included: 1. Review of the hospital’s policy titled, “Discharges, PC-021” dated 3/2023 revealed, “... Planned Discharge... Practitioner’s order will be written in the patient medical record... Nursing staff will assist the patient in... Understanding discharge instructions... The therapist will complete the aftercare plan and patient choice letter ensuring that appropriate aftercare appointments are scheduled to provide a continuum of care... The therapist will secure aftercare appointments and ensure hand off communication with aftercare providers...” 2. Medical record review for Patient #1 revealed an admission date of 4/26/2024 with diagnoses which included Major Depressive Disorder, Recurrent Severe with Psychotic Features and Unspecified Dementia with Behavioral Disturbances. Review of the Intake assessment completed 4/26/2024 revealed Patient #1’s daughter took her to the hospital because the patient was “... not presenting with normal behaviors. Rambling and confusion were some of the symptoms presenting with the patient during the assessment. When the pt. [patient] was questioned about her daughter the pt. began talking about other family members and a recent stroke event. Per collateral [patient’s daughter] the pt. did not suffer from a stroke. Pt. seems to be oriented x [times] 3 (person, place, time)... Per collateral the pt cannot recall how to get home from church that she’s been attending for years. The pt. reported the car knows where it’s going... the pt. begins to cry when she thinks of events from the past... the pt. is frequently crying. Last week the pt. cried profusely over an individual [daughter] claims she didn’t really know... Pt. drove 2 hrs [hours] away by herself when she knows she’s not supposed to be driving per agreement between mother and daughter... pt. also reportedly spends impulsively... Due to the pt not complying with meds it’s been reported that she is up all night calling her children... The pt. presented with rambling info [information] that didn’t make sense...” Review of the Admission Order dated 4/26/2024 revealed, “... Admit to Inpatient, inclusive of groups/programming... Legal Status... Involuntary...” Review of the First Certificate of Need for Emergency Involuntary Admission dated 4/26/2024 at 8:15 PM revealed, “... Currently pt is a danger to self and others as evidenced by poor impulse, poor judgment [judgement] and poor insight... Patient is currently unable to contract for safety. Patient needs a safe and secure setting for adjusting to medications and treatment. Patient is at too high risk of danger to self to release into the community at this time...” Review of the Second Certificate of Need for Emergency Involuntary Admission dated 4/27/2024 at 2:10 AM revealed, “... Risk to self + [and] others [symbol for secondary to] agitation... Risk to self + others [symbol for secondary to] noncompliance... unable to contract for safety...” Review of the Psychiatric Evaluation dated 4/27/2024 at 10:00 AM revealed, “... presents for initial eval [evaluation] secondary to an increase in confusion and mood swings according to intake information provided by daughter. Reported as more confused, rambling and ‘Just not herself.’ Reported as not answering c [with] correct responses, forgetting how to get home, or where her church is in which she has gone for years. Mood is more depressed and explained an overly emotional/crying over minimal things, more delusional - Not supposed to be driving and forgetful and where she’s going. Stated, ‘The car knows where it’s supposed to go.’... Hx [history of ] med [medication] noncompliance Multiple admissions to inpt [inpatient] psychiatry... Negative for any suicidal attempts... Estimated Length of Stay...7 - 10 days...J ustification for Hospitalization... Hallucinations, delusions, agitation, anxiety, depression resulting in significant loss of functioning... Inability to meet basic life and health needs...” Patient #1’s medications were adjusted, and she attended and participated in group therapy throughout her hospitalization. A Psychiatric Progress Noted dated 5/2/2024 revealed Patient #1 was “Asking about a discharge date... her daughter lied...that’s why she’s here calm, cooperative... Medication Adjustment... [symbol for increase] Risperdal [a medication used to treat psychosis]...[symbol for increase] Lexapro [a medication used to treat depression]... Response to Treatment... Treatment goals achieved and patient stable for discharge or step down... Estimated Date of Discharge: 5/3/24...” Review of the Discharge Order dated 5/2/2024 revealed, “... Date of Discharge: 5/3/24...” Further review of the order revealed the patient’s home medications were listed, but there was no documentation of recommendations for follow up care noted. Review of a Psychiatric Progress Note dated 5/3/2024 revealed, “... pt seen; she appears to be in a good mood; denies SI [suicidal ideations], HI [homicidal ideations] or psychosis; speech has slowed down; compliant c [with] meds, tolerating recent [symbol for increase] in Risperdal + Lexapro... Estimated Date of Discharge... scheduled today...” Review of the Discharge Care Plan and Home Medications form dated 5/3/2024 and signed by facility staff member at 8:03 AM and by Patient #1 at 8:09 AM revealed the patient’s home medications were listed, but there was no documentation of any after care plans or follow up appointments. In a telephone interview on 5/13/2024 at 2:31 PM, Patient #1’s daughter stated neither Patient #1 or a family member received any information regarding her post-hospitalization plans. The daughter further stated she called the hospital on 5/6/2024 regarding after care plans and was informed she could bring the patient to the hospital’s Outpatient Center. Upon arrival to the Outpatient Center, the daughter stated she was informed by the Outpatient Therapist that there were no after care plans in Patient #1’s medical record. In an interview on 5/14/2024 at 1:12 PM, the Psychiatrist was asked why the discharge orders didn’t have any after care instructions documented. The Psychiatrist stated the therapists make all the after care plans and appointments for the patients, so she didn’t ever fill in that portion of the discharge order. In an interview on 5/14/2024 at 1:13 PM, the Nurse Practitioner (NP) stated she didn’t know why there were no after care plans documented in the patient’s medical record. In an interview on 5/14/2024 at 3:00 PM, the Outpatient Therapist verified Patient #1 presented to the hospital’s Outpatient Center on Monday, May 6, 2024, but there were no after care plans documented in the patient’s medical record, so she referred her back to Intake to be reassessed. In an interview on 5/14/2024 at 3:22 PM, the Chief Executive Officer verified there were no after care plans documented for Patient #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: 49645 Based on contract review, document review, and interview, the Governing Body failed to ensure patients were provided safe care by trained and competent staff for 2 of 2 (Agency staff #1 and #2) agency staff reviewed. The findings included: 1. Review of a Client Service Agreement (contract) between the staffing agency and hospital, revealed the client (Corporation owning hospital) acknowledged the providers (Behaviorial Health Associates (BHA), Certified Nuring Assistant (CNA), Licensed Practical Nurse (LPN), and Registered Nurse (RN) were independent contractors operating as self-employed individuals who used staffing agencies’ platforms and services to offer and provide halthcare services to clients/patients. The hospital maintained no employee or training records on the agency staff. The hospital did not conduct background checks or checks of the Abuse Registry on agency staff. Agency staff were not required to complete an orientation that included training and competencies required of this hospital’s staff prior to assigment to work on a unit. Agency staff were not required to complete the mandatory training in Cardiopulmonary Resuscitation (CPR), Abuse, Seclusion & Restraint, Handle-with-Care/de-escalation techniques prior to beginning work on the units at the hospital. Review of agency staff training records and competencies revealed there was no documentation of mandatory training records and competencies for Agency staff #1 and Agency staff #2. In an interview on 02/23/2024 at 9:10 AM, the Human Resources Director stated there was no formal process for monitoring agency staff for mandatory training and competencies required prior to beginning direct patient care. Refer to A-084”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35244 Based on policy review, document review, and interview, the facility failed to ensure patients’ rights to be free from verbal and physical abuse by staff were protected as evidence by review of the hospital incidents for 5 of 13 (Incident #1, #2, #3, #4, #5) reviewed abuse incidents related to staff. The findings included: 1. Review of the facility’s “Workplace Violence Policy, #HR [Human Resource] - 620” policy revealed, “... [named Corporation] had a Zero Tolerance approach to workplace violence and was committed to providing an environment free from all forms of violence for its employees, patients, families, and vendors...” Review of the facility’s “Patient Abuse and Neglect, #HR-001” policy revealed, “.....Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect, and exploitation. [Named Hospital] shall protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members... Mental/Psychological Abuse... Acts that inflict emotional harm, invoke fear and/or humiliate, intimidate, degrade, demean or otherwise negatively impact the mental health...” Review of the facility’s “Patient Rights and Responsibilities” policy revealed, “... Patients have the following rights... Patients have the right to be treated with consideration, respect, and full recognition of their dignity and individuality... Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse... “ 2. Review of the Grievance/Complaint Log data from 9/1/2023 to 2/21/2024 revealed 5 complaints of patient abuse by staff that were substantiated by the hospital upon completion of their investigation. Review of Incident #1 revealed on 10/27/23 on the East Unit, Patient #1 reported verbal and physical abuse by Behavioral Health Associates (BHA) #1. BHA #1 was terminated upon the completion of the facility’s investigation. Review of Incident #2 revealed on 10/31/23 on the East Unit, Medical Doctor (MD) #1 reported witnessing BHA #2 yelling and cursing at Patient #2. BHA #2 was placed on administrative leave during the facility’s investigation and required to complete zero tolerance training. Review of Incident #3 revealed on 11/24/23 on the North Unit, several staff members (unnamed) reported witnessing Registered Nurse (RN) #1 cursing at Patient #3. RN #1 received a “final warning” disciplinary action and was to complete zero tolerance training and customer service training. Review of Incident #4 revealed on 1/21/24 on the East Unit, Activity Therapy Manager #1 reported BHA #3 was overheard calling patients “ugly”, telling patients she wasn’t there to do what the patient says, and telling a patient to “jump”. BHA #3 received a “final warning” as a disciplinary notice. Review of Incident #5 revealed on 2/12/24 on the North Unit, Patient #4 reported BHA #4 exchanged words with him and became verbally aggressive after being told she didn’t know how to do her job. BHA #4 was terminated upon completion of the facility’s investigation. 3. In an interview on 02/21/2024 at 11:00 AM, the Interim Risk Manager stated she reviewed the Incident Logs, did a risk analysis, and made sure the witness statement was completed. She dealt only with the patient aspect of the incident. She would only do a root cause analysis if a patient was attacked by staff. She had to do a root cause analysis if violent, aggressive patients either engaged in self-harm or physical confrontations with staff or other patients. She hadn’t yet encountered anything that had repeatedly occurred. In an interview on 02/21/2024 at 12:00 PM, the Quality Director (QD) stated she reviewed the Grievance/Complaint logs in the Quality Council monthly meetings and verified she hasn’t done anything with the Incident Log. The QD stated the Risk Director was responsible for handling all incident reports and some risk reports. In an interview on 02/21/2024 at 1:00 PM, the Patient Advocate stated he worked with the Interim Risk Management, talked with her every morning, and addressed patient complaints with her via Flash Notes (online marketplace to buy and sell course specific notes, flashcards, and other items) and TEAMS (video conferencing service) meetings. The Patient Advocate stated he had no interaction with the Compliance Manager. Refer to A145.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 35244 Based on policy review, document review, medical record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program fully analyzed adverse events (incidents) and implemented measures to prevent future occurrences for 2 of 3 (Patients #2 and #4) sampled patients reviewed with adverse events, and failed to track, analyze and implement preventative measures for all other adverse events as part of the facility wide QAPI program. The findings included: 1. Review of the facility’s “PROCESS IMPROVEMENT PROGRAM” policy revealed, “...The Process Improvement Program is designed to provide a coordinated, objective, and systematic approach to facility-wide quality assurance activities...Objectives are...To foster a safe and just culture so that errors are managed appropriately through supportive systems, education on at-risk behaviors, and correction as needed...Review incident report data...to determine the presence or absence of patterns and/or trends or opportunities for improvement in patient care outcomes, as well as the appropriateness of corrective action...” Review of the facility’s “Risk Management Incident Investigation Policy” revealed, “...It is the policy of [named hospital] to utilize investigation as a preventative tool to strive to avoid incidents from reoccurring and to improve quality of care...” 2. Medical record review for Patient #2 revealed an admission date of 10/6/2023 with admitting diagnosis of Schizoaffective Disorder, Depressive type. Review of the facility’s Incident Report beginning 9/1/2023 through 2/21/2024 revealed on 10/7/2023 Patient #2 with an incident description of “Restraint”. The incident “Summary” revealed Patient #2 became upset after her initial assessment. Patient #2 became “irate” (great anger) and stated would self-harm. A physician ordered chemical and physical restraint to calm Patient #2. There was no documentation the facility implemented specific measures to help prevent future incidents involving Patient #2. 3. Medical record review for Patient #4 revealed an admission date of 2/7/2024 with admitting diagnosis of Major Depressive Disorder, recurrent, severe with psychosis. Review of the facility’s Incident Report beginning 9/1/2023 through 2/21/2024 revealed on 2/11/2024 Patient #4 had 2 incidents of restraints, and 1 incident of seclusion. On 2/12/2024 Patient #4 had 2 incidents of restraints, and 1 incident of seclusion. There was no documentation the facility implemented specific measures to help prevent future incidents involving Patient #3. 4. Review of Performance Improvement meeting minutes beginning September 2023 through February 2024 revealed the following: -November 3, 2023 meeting; review of September 2023 data revealed, “ ...We had a total of 71 incidents in September ...Action To Be Taken ...” There was no documentation the facility tracked, analyzed and implemented specific measures to address incidents for September 2023. -December 1, 2023 meeting; review of October 2023 data revealed, “ ...QAPI ...We had 74 incidents in October ...Action To Be Taken ...Continue to look at data for the quarter and make PI [Performance Improvement] teams for 2024...” There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address incidents for October 2023. -December 22, 2023 meeting; review of November 2023 data revealed, “ ...QAPI ... We had 66 incidents in November ...Action To Be Taken ...Make sure we are properly documenting with Suicide gestures. Will educate nursing staff ...” There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address incidents for November 2023. -February 9, 2024 meeting; review of December 2023 data revealed, “ ...QAPI ...We had 112 incidents in December ...Risk is having safety Huddles daily. Significant increase in December. Numbers are higher because more are being reported even when they are being handled ...Action To Be Taken ...Several patients were responsible for multiple incidents and more high acuity patients made for higher numbers ...” There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address the significant increase in incidents for December 2023. -March 1, 2024 meeting; review of January 2024 data revealed no documentation of incident data for January 2024. -March 22, 2024 meeting; review of February 2024 data revealed no documentation of incident data for February 2024. In an electronic mail (email) communication with the Administrator on 02/28/2024 at 4:00 PM, the Administrator addressed the increased December incidents stating, “... No root cause analysis was done. Incidents were discussed in Quality and flash meetings and recommendations made to ensure safety...” Refer to A 0286.”

“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: 49645 Based on policy review, document review, medical record review observation and interview, the hospital failed to ensure the Director of Nursing (DON) operated an organized nursing service for 4 of 4 (East, North, South, West) units reviewed, failed to ensure nursing services provided adequate oversight and supervision for safe care for 2 of 4 (Patients #2 and #4) sampled patients, failed to follow the staff patient ratio goal for 20 of 20 (10/6/2023 - 10/19/2023 and 2/7/2024 - 2/12/2024) days reviewed and failed to ensure medications were administered per physician order for 7 of 7 (Patients #5, 6, 7, 8, 9,10 and 11) patients reviewed for medication variances. The findings included: 1. Review of the job description for “Chief Nursing Officer [CNO; also called Director of Nursing (DON)]” revealed, “... Purpose Statement: Direct, plan, coordinate, monitor and supervise the effective use of the operations of nuring...” Request to review organizational chart for Nursing Services revealed the facility was unable to provide documentation of an organizational chart for Nursing Services. In an interview on 02/04/2024 at 11:55 AM, the Administrator verified there was no organizational chart for Nursing Services. Refer to A-0386 2. Review of the facility’s “PATIENT RIGHTS AND RESPONSIBILITIES” policy revealed, “ ...Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse ...” Review of the facility’s “ASSIGNMENT OF NURSING STAFF” policy revealed, “ ...It is the policy of this facility to maintain a staffing level, which supports safe and effective care for each clinical program...” 3. Medical record review for Patient #2 revealed an admission date of 10/6/2023 with diagnoses that included Schizoaffective Disorder, Depressive type. On 10/07/2023, Patient #2 became upset over involuntary status, threatening to kill self, refused as needed (PRN) medication, and attempted to barricade self in day room. Patient #2 required physical restraint by staff for administration of a PRN medication. On 10/10/2023, Patient #2 became upset again after meeting with the patient advocate. Patient #2 began beating on the nurse’s station window and medication room window, yelling, screaming, and threatening to slap a staff member. Patient #2 required chemical and physical restraint, with seclusion ultimately ordered. Nursing oversight failed to prevent Patient #2 from endangering himself through behaviors, and failed to prevent staff and other patients from physical harm by Patient #2. Review of the daily staffing and census beginning 10/6/2023 through 10/19/2023 for the East Unit (where Patient #2 was housed) revealed the facility failed to meet their staff ratio goal of 1 staff to 5 patients on each day reviewed. 4. Medical record review for Patient #4 revealed an admission date of 2/7/2024 with diagnoses that included Schizoaffective disorder, Depressive type. Patient #4 was involved in incidents including restraint (physical and chemical), seclusion and attacks on staff beginning 2/8 -2/12/2024. Patient #4’s incidents on 2/12/2024 resulted in a fractured arm. Nursing oversight failed to ensure Patient #4 was free from injury, including a fractured arm, after repeated, ongoing behaviors while admitted to the facility. Review of the daily staffing and census beginning 2/7/2024 through 2/12/2024 on the East Unit revealed the facility failed to meet the staff ratio goal of 1 staff to 5 patients on each day reviewed. 5. Observations on the North Unit on 02/21/2024 at 9:20 AM, revealed there were twenty (20) patients on the unit. Two (2) Behavioral Health Associates (BHAs) were present. Nineteen (19) patients required monitoring every fifteen (15) minutes. One (1) patient required monitoring every five (5) minutes. The ratio of Behavioral Health Associates (BHA) to patients was 2:20. Observations on the South Unit on 02/21/2024 at 9:30 AM, revealed seventeen (17) patients were on the unit, one (1) BHA, two (2) Registered Nurses (RN), and one (1) Licensed Practical Nurse (LPN). 6. In an interview on 02/21/2024 at 9:50 AM, the Chief Financial Officer (CFO) reported the staffing ratio goal for direct care staff to patients is one (1) staff to five (5) patients. In an interview on 02/21/2024 at 10:05 AM, RN #2 stated there was sometimes only one behavior health assistant on the unit. In an interview on 02/21/2024 at 10:15 AM, RN #1 stated there was not sufficient staff on the units, and the units were short of staff every day. RN #1 stated the lack of sufficient staffing made it more dangerous for patients and staff. Refer to A-0392. 7. Review of the facility’s “MEDICATION ADMINISTRATION AND DOCUMENTATION” policy revealed, “...All ordered medications administered to patients will be documented on the Medication Administration Record...Check patient’s Medication Administration Record (MAR) to ensure that the order is accurate...” Review of the facility’s Incident Report log beginning 9/1/2023 through 2/21/2024 revealed 7 patient related medication variances. Medical record review for Patient #5 revealed a Zyprexa dose on 9/29/2023 was given in the evening at approximately 9:00 PM, instead of 9:00 AM as ordered. Medical record review and Incident Report log review for Patient #6 revealed on 9/30/2023 Tramadol (opioid analgesic) 50 milligram (mg) was given instead of ordered Trazadone. Medical record review and Incident Report log review for Patient #7 revealed the patient did not recieve ordered Celexa that had been brought from home due to the medication could not be located. Medical record review for Patient #8 revealed Trazodone 50 mg was administered at 1:45 PM instead of at bedtime as ordered. Medical record review and Incident Report log for Patient #9 revealed Patient #9 identified herself as another patient to a nurse administering medications. Patient #9 received a dose of Trazadone 50 mg that was not prescribed to her. Medical record review for Patient #10 revealed the patient received an ordered dose of Vistaril 3 hours and 40 minutes after it was instructed to be given “now”. Medical record review and Incident Report log review for Patient #11 revealed the patient received the wrong dose of Haldol on 2/4/2024. Refer to A-0405.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 49645 Based on contract review, document review and interview, the Governing Body failed to ensure staff under contract were trained and competent to provide care in a safe and effective manner for 2 of 2 (Agency staff #1 and #2) agency staff reviewed. The findings included: 1. Review of a Client Service Agreement (contract) between the staffing agency and hospital, with an effective date of 02/17/2023, revealed the client Corporation owning the hospital acknowledged the providers (Behavioral Health Associates (BHA), Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), and Registered Nurse (RN)) were independent contractors operating as self-employed individuals who used the staffing Agency platforms and services to offer and provide healthcare services to clients/patients. The hospital maintained no employee or training records on the agency staff. The hospital did not conduct background checks or checks of the Abuse Registry on agency staff. The hospital staff reported that the staffing agency had a portal where the agency staff training could be viewed. The hospital did not verify information viewed in that portal. Agency staff were not required to complete an orientation that included training and competencies required of this hospital’s staff prior to assignment to work on a unit. Agency staff were not required to complete the mandatory training in Cardiopulmonary Resuscitation (CPR), Abuse, Seclusion & Restraint, Handle-with-Care/de-escalation techniques prior to beginning work on the units at the hospital. Agency staff were not allowed to provide any hands-on-care and could not assist with combative or aggressive patients, holding patients for as needed (PRN) injections ordered for agitated/combative patients, restraints, or seclusion of patients. Agency staff were included in the unit staff/patient ratios (even though the agency staff could not provide hands-on-care or assistance with combative/aggressive patients). 2. Review of agency staff training and competency records for Agency staff #1 revealed no documentation of mandatory training records and competencies. 3. Review of agency staff training and competency records for Agency staff #2 revealed no documentation of mandatory training records and competencies. In an interview on 02/21/2024 at 9:00 AM, the Administrator stated agency staff did not provide hands-on care if the patient required physical restraint. The Administrator stated the agency staff should not touch the patient at all if it was related to Handle-with-Care/de-escalation and agency staff cannot provide physical assistance in dealing with combative/aggressive patients. The Administrator stated agency staff cannot hold patients for as needed (PRN) medications. The Administrator stated she was not sure if the hospital had a written policy regarding this and stated the hospital had verbally communicated with the Agency regarding this rule. When questioned whether the hospital rule was documented anywhere, the Administrator replied that it was a “yes/no” answer. She stated, “In the beginning, we did have them sign off that they received it (the rule that agency staff did not provide hands-on care for patients), but some have been done just verbally by nursing leadership.” In an interview on 02/23/2024 at 9:10 AM, the Human Resources Director stated there was no formal process for monitoring agency staff for mandatory training and competencies required prior to beginning direct patient care.”

“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: 49645 Based on policy review, document review, and interview, the facility failed to ensure patients’ rights to be free from verbal and physical abuse by staff were protected as evidence by review of 5 of 13 (Incident #1, #2, #3, #4, #5) reviewed abuse incidents related to staff. The findings included: 1. Review of the hospital’s policy “Workplace Violence Policy, #HR [Human Resource] - 620” with an effective date of 12/09/2007 and revised 09/01/2015 revealed, “... [named Corporation] had a Zero Tolerance approach to workplace violence and was committed to providing an environment free from all forms of violence for its employees, patients, families, and vendors. Workplace violence included but was not limited to harassment, intimidation, threats (verbal, written, or physical) or acts of physical assault and other disruptive behavior...” Review of hospital’s policy “Patient Abuse and Neglect, #HR-001” dated 12/20/2021 revealed, “.....Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect, and exploitation. [Named Hospital] shall protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members... Mental/Psychological Abuse... Acts that inflict emotional harm, invoke fear and/or humiliate, intimidate, degrade, demean or otherwise negatively impact the mental health... Examples include derogatory, threatening, belittling, humiliating, or profane or obscene language toward a patient, physical intimidation... Verbal Abuse... The use of offensive and/or intimidating language that can provoke or upset an individual... Examples include cursing /verbally threatening a patient, cursing/verbally threatening in front of a patient even if not directed toward the patient, verbally criticizing a patient and family...” Review of the hospital’s policy “Patient Rights and Responsibilities” dated 12/2021 and reviewed 3/2023 revealed, “... Patients have the following rights... Patients have the right to be treated with consideration, respect, and full recognition of their dignity and individuality... Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse... “ 2. Review of the Grievance/Complaint Log data from 9/1/2023 to 2/21/2024 revealed 5 complaints of abuse by staff that were substantiated by the hospital upon completion of their investigation. Review of Incident #1 revealed on 10/27/23 on the East Unit, Random Patient #1 reported verbal and physical abuse by Behavioral Health Associates (BHA) #2. Random Patient #1 reported BHA #2 flipped him out of a chair, pushed him in the back, and called him “sissy” and “faggot”. East Unit had a census of 26 patients and was staffed by 2 nurses, 3 BHAs and 1 supervisor at the time of the reported abuse. BHA #2 was terminated upon the completion of the facility’s investigation. Review of Incident #2 revealed on 10/31/23 on the East Unit, MD #1 reported witnessing BHA #3 yelling and cursing at Random Patient #2. East Unit had a census of 26 patients and was staffed by 2 nurses and 4 BHAs at the time of the reported abuse. BHA #3 was placed on administrative leave during the facility’s investigation and required to complete zero tolerance training. BHA #3’s zero tolerance training was not completed until 12/1/23, after he returned to work on 11/9/23. Review of Incident #3 revealed on 11/24/23 on the North Unit, several staff members (unnamed) reported witnessing RN #10 cursing at Random Patient #3. RN #1 told Random Patient #3 “Fuck you”. North Unit had a census of 17 patients and was staffed by 2 nurses and 2 BHAs at the time of the reported abuse. RN #1 received a “final warning” disciplinary action and was to complete zero tolerance training and customer service training. Review of RN #1’s training revealed Zero Tolerance training was not completed until 1/12/24. There was no documentation of customer service training. Review of Incident #4 revealed on 1/21/24 on the East Unit, Activity Therapy Manager #1 reported BHA #4 was overheard calling patients “ugly”, telling patients she wasn’t there to do what the patient says, and telling a patient to “jump”. East Unit had a census of 27 patients and was staffed by 2 nurses and 3 BHAs at the time of the reported abuse. BHA #4 received a “final warning” as a disciplinary notice. Review of Incident #5 revealed on 2/12/24 on the North Unit, Random Patient #4 reported BHA #5 exchanged words with him and became verbally aggressive after being told she didn’t know how to do her job. North Unit had a census of 19 patients and was staffed by 3 nurses and 2 BHAs at the time of the reported abuse. BHA #5 was terminated upon completion of the facility’s investigation. 3. In an interview on 02/21/2024 at 11:00 AM, the Interim Risk Manager (RM) stated her role was to identify facility risks, including environmental risks. The Interim RM stated she collected, reviewed, and entered incident reports into the system. The Interim RM stated she did morning rounds on each unit, pulled out the incident report, looked at the report while on the unit, and mentioned concerns to the nurse and other staff while on the unit. The Interim RM stated she completed investigations of incident reports and discussed findings in the daily Leadership Meeting and identified any risks and immediately acted to mitigate those risks. The Interim RM stated she had never heard of a Quality Assurance and Performance Improvement (QAPI) Team or QAPI Report. The Interim RM stated she would only do a root cause analysis if a patient was attacked by staff and would do a root cause analysis if violent, aggressive patients either engaged in self-harm or physical confrontations with staff or other patients. The Interim RM stated she hadn’t yet encountered anything that had repeatedly occurred. In an interview on 02/21/2024 at 12:00 PM, the Quality Director (QD) stated she reviewed the Grievance/Complaint logs in the Quality Council monthly meetings but did not do anything with the Incident Log. The QD stated the Risk Director was responsible for handling all incident reports and some risk reports. In an interview on 02/21/2024 at 1:00 PM, the Patient Advocate stated he worked with Risk Management, talked with her every morning, and addressed patient complaints with her via Flash Notes (online marketplace to buy and sell course specific notes, flashcards, and other items) and TEAMS (video conferencing service) meetings. The Patient Advocate stated he had no interaction with the Compliance Manager.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 49645 Based on policy review, document review, medical record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program fully analyzed adverse events (incidents) and implemented measures to prevent future occurrences for 2 of 3 (Patients #2 and #4) sampled patients reviewed with adverse events, and failed to track, analyze and implement preventative measures for all other adverse events as part of the facility wide QAPI program. The findings included: 1. Review of the facility’s “PROCESS IMPROVEMENT PROGRAM” policy (revised 1/2024) revealed, “...The Process Improvement Program is designed to provide a coordinated, objective, and systematic approach to facility-wide quality assurance activities...Objectives are...To foster a safe and just culture so that errors are managed appropriately through supportive systems, education on at-risk behaviors, and correction as needed....Facility-wide quality assessment and robust process improvement activities include...medication use, safety, risk management...The authority and responsibility of the Performance Improvement Director includes...Review incident report data, patient surveys, employee surveys such as Culture of Safety survey, and patient complaints to determine the presence or absence of patterns and/or trends or opportunities for improvement in patient care outcomes, as well as the appropriateness of corrective action...” Review of the facility’s “Risk Management Incident Investigation Policy” (reviewed 3/2023) revealed, “...It is the policy of [named hospital] to utilize investigation as a preventative tool to strive to avoid incidents from reoccurring and to improve quality of care. Additionally, investigations help to cultivate an educational mindset of safety amongst all levels of employees at the facility...” 2. Medical record review for Patient #2 revealed an admission date of 10/6/2023 with admitting diagnosis of Schizoaffective Disorder, Depressive type. Patient #2 was an involuntary admission who was hearing voices, paranoid, agitated, confused, and considered a danger to self and others. Patient #2 was housed on the East Unit. Review of the facility’s Incident Report beginning 9/1/2023 through 2/21/2024 revealed on 10/7/2023 Patient #2 with an incident description of “Restraint”. The incident “Summary” revealed Patient #2 became upset after her initial assessment. Patient #2 became “irate” (great anger) and stated would self-harm. A physician ordered chemical and physical restraint and documented they were required to calm Patient #2. There was no documentation the facility implemented specific measures to help prevent future incidents involving Patient #2. 3. Medical record review for Patient #4 revealed an admission date of 2/7/2024 with admitting diagnosis of Major Depressive Disorder, recurrent, severe with psychosis. Patient #4 had a suicidal plan to cut her throat with a knife, was psychotic, and hearing command voices. Patient #4 was housed initially on the North Unit. Review of the facility’s Incident Report beginning 9/1/2023 through 2/21/2024 revealed on 2/11/2024 Patient #4 had 2 incidents of restraints, and 1 incident of seclusion. On 2/12/2024 Patient #4 had 2 incidents of restraints, and 1 incident of seclusion. Patient #4 had reportedly punched windows, walls, made verbal and physical threats toward staff, climbed over a nursing station, and verbalized wanting to self-harm. There was no documentation the facility implemented specific measures to help prevent future incidents involving Patient #3. 4. Review of the facility’s Incident Report documentation beginning 9/1/2023 through 2/21/2024 revealed the following: September 2023 Incidents included: “Restraints (included holds and seclusion)- 6, Patient to Patient altercations- 14, Patient to Staff altercations- 3, Falls (observed and unobserved)- 2, Misconduct (included boundary violations and sexual misconduct)- 5, Physician orders not carried out- 1, Property Damage- 1, Contraband- 2, Medication variances- 2”. October 2023 Incidents included: “Restraints- 13, Patient to Patient altercations- 12, Patient to Staff altercations- 1, Falls- 7, Misconduct- 4, Property Damage- 3, Contraband- 6, Medication variances- 2, Self-inflicted injuries- 5, Staff to Patient alleged abuse (verbal/physical)- 3”. November 2023 Incidents included: “Restraints-5, Patient to Patient altercations- 9, Patient to Staff altercations- 3, Falls- 4, Misconduct- 9, Property Damage- 3, Contraband- 3, Medication variances- 2, Self-inflicted injuries- 1, Staff to Patient alleged abuse- 2, Suicidal gesture- 3”. December 2023 Incidents included: “Restraints- 20, Patient to Patient altercations- 28, Patient to Staff altercations- 2, Falls- 10, Misconduct- 6, Property Damage- 9, Contraband- 4, Medication variances- 1, Self-inflicted injuries- 2, Suicidal gestures- 2, attempted elopement- 2”. January 2024 Incidents included: “Restraints- 9, Patient to Patient altercations- 17, Patient to Staff altercations- 6, Falls- 7, Misconduct- 1, Property Damage- 2, Contraband- 2, Self-inflicted injuries- 5, Physician orders not carried out- 1, Patient wandering- 1, Staff to Patient alleged abuse- 2”. February 2024 Incidents included: “Restraints- 19, Patient to Patient altercations- 16, Patient to Staff altercations- 2, Falls- 1, Misconduct- 4, Property Damage- 1, Contraband- 2, Medication variance- 3, Suicidal gestures- 3, Staff to Patient alleged abuse- 1”. Review of Performance Improvement meeting minutes beginning September 2023 through February 2024 revealed the following: November 3, 2023 meeting; “review of September 2023 data” revealed, “...QAPI ...Risk Management Scorecard/Incidents- We had a total of 71 incidents in September ...Action To Be Taken ...” There was no documentation the facility tracked, analyzed and implemented specific measures to address incidents for September 2023. December 1, 2023 meeting; “review of October 2023 data” revealed, “ ...QAPI ...Risk Management Scorecard/Incidents- We had 74 incidents in October ...Action To Be Taken ...Continue to look at data for the quarter and make PI [Performance Improvement] teams for 2024. CEO [Chief Executive Officer] talk with Risk to update training in orientation to review zero tolerance/abuse ...” There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address incidents for October 2023. December 22, 2023 meeting; “review of November 2023 data” revealed, “ ...QAPI ... Risk Management Scorecard/Incidents- We had 66 incidents in November ...Sexual intercourse Pt/Pt [patient to patient] increased from 0 to 3 and Suicide gestures went from 0 to 3 ...Action To Be Taken ...Make sure we are properly documenting with Suicide gestures. Will educate nursing staff ...” There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address incidents for November 2023. February 9, 2024 meeting; “review of December 2023 data” revealed, “ ...QAPI ...Risk Management Scorecard/Incidents- We had 112 incidents in December ...Risk is having safety Huddles daily. Significant increase in December. Numbers are higher because more are being reported even when they are being handled ...Action To Be Taken ...Several patients were responsible for multiple incidents and more high acuity patients made for higher numbers ...” There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address the significant increase in incidents for December 2023. March 1, 2024 meeting; “review of January 2024 data” revealed no documentation of incident data for January 2024. March 22, 2024 meeting; “review of February 2024 data” revealed no documentation of incident data for February 2024. In an electronic mail (email) communication with the Administrator on 02/28/2024 at 4:00 PM, the Administrator addressed the increased December incidents stating, “... No root cause analysis was done. Incidents were discussed in Quality and flash meetings and recommendations made to ensure safety...moving patients to different units...Plan addressed...added to 2024 PI [Performance Improvement] Plan under Risk/Workplace Violence Committee...””

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 49645 Based on job description review, document review and interview, the facility failed to ensure the Director of Nursing (DON) was responsible for and operated an organized Nursing Service for 4 of 4 units (North, South, East, and West) reviewed. The findings included: 1. Review of the job description for “Chief Nursing Officer [CNO; also called Director of Nursing (DON)]” dated 01/01/2020 revealed, “... Purpose Statement: Direct, plan, coordinate, monitor and supervise the effective use of the operations of nursing... and the delivery of behavioral health/nursing services... Manage the daily operations of nursing services... Evaluate service needs and staffing requirements to ensure needs of patients are met...” 2. Request to review organizational chart for Nursing Services revealed the facility was unable to provide documentation of an organizational chart for Nursing Services. 3. In an interview on 02/04/2024 at 11:55 AM, the Administrator verified there was no organizational chart for Nursing Services. In an interview on 02/21/2024 at 12:20 PM, the Chief Nursing Officer (CNO) stated she began her position at the hospital on January 12, 2024. The CNO stated the Unit assignments for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Behavioral Health Associates (BHAs) were completed by the Staff Coordinator and that the Staff Coordinator, Assistant Director of Nursing (ADON), and CNO reviewed the unit staffing assignments every morning. The CNO stated the person who completed the changes in staffing assignment depended on the time of day. The CNO stated she did not feel that the current staff/patient ratio was safe for patients and staff and verified she was unaware of what the staff ratio parameters should be. The CNO stated she had heard it was one (1) staff to five (5) patients. The CNO stated that the Chief Executive Officer and Chief Financial Officer configured the census needs. The CNO stated the appropriate number of staff to assign to a unit was determined by the staff/patient ratio and patient needs to staff and that the hospital “is not sticking to either one.” The CNO stated she was told by the previous CNO that the parameters for staff to patient ratio was 1:5 and that ratio also included the nurses. The CNO stated she was involved in the Governing Body Meetings and had been to one (1) Quality Meeting.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 49645 Based on policy reivew, document review, medical record review, observation and interview, the facility failed to ensure Nursing Services provided adequate oversight and supervision of nursing staff to ensure patients were provided care in a safe setting for 2 of 4 (Patients #2, #4) sampled patients and failed to follow their staff to patient ratio goal of one (1) staff for every five (5) patients for 20 of 20 (10/6/2023 - 10/19/2023 and 2/7/2024 - 2/12/2024) days reviewed. The findings included: 1. Review of the facility’s “PATIENT RIGHTS AND RESPONSIBILITIES” policy (reviewed 3/2023) revealed, “ ...Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse ...” Review of the facility’s “ASSIGNMENT OF NURSING STAFF” policy (reviewed 4/18/23) revealed, “ ...It is the policy of this facility to maintain a staffing level, which supports safe and effective care for each clinical program ...1. Nursing Services use a 24-hour staffing pattern. a. Nurse is assigned to each shift. b. Nurse provides supervision on the shifts ...d. Staffing increases with acuity and changes in census, assessed by the Nurse and/or Supervisor and communicated to Nursing Administration ...” 2. Review of the facility’s “Chief Nursing Officer[CNO]” job description revealed, “ ...Direct, plan, coordinate, monitor and supervise the effective and efficient use of the operations of nursing, other departments and the delivery of behavioral health/nursing services with a positive, empathetic, and professional attitude toward customers. Recognize that patient safety is a top priority ...Evaluate service needs and staffing requirements to ensure needs of patients are met ... Review of the facility’s “RN [Registered Nurse]” job description revealed, “ ...Responsible for providing professional nursing care to patients with a positive, empathetic, and professional attitude to foster a supportive and therapeutic environment. Recognize that patient safety is a top priority ...” Review of the facility’s “BEHAVIORAL HEALTH ASSOCIATE “ job description revealed, “ ...Responsible for providing personal care services to patients at the facility under the direction of clinical or nursing leadership ...Assist in providing a safe, secure and comfortable environment for patients, significant others and staff ...” 3. Medical record review for Patient #2 revealed an admission date of 10/6/2023 with diagnoses that included Schizoaffective Disorder, Depressive type. Patient #2 was an emergency involuntary admission who was hearing voices, paranoid, very agitated, confused and a danger to self and others. Patient #2 was housed on the East Unit. (Patient #2 was discharged from the facility on 10/19/2023). On 10/07/2023, Patient #2 became upset over involuntary status, threatening to kill self, refused as needed (PRN) medication, and attempted to barricade self in day room. Patient #2 required physical restraint by staff for administration of a PRN medication. On 10/10/2023, Patient #2 became upset again after meeting with the patient advocate. Patient #2 began beating on the nurse’s station window and medication room window, yelling, screaming, and threatening to slap a staff member. Patient #2 required chemical and physical restraint, with seclusion ultimately ordered. Review of a 10/15/2023 Psychiatry Progress Note documented, “ ...easily influenced and provoked. Reported as assaulting another patient on yesterday ...Behaviors remain unpredictable ...” There was no documentation of nursing oversight or a nursing plan to prevent Patient #2 from endangering himself through behaviors, and no documentation of nursing oversight and a plan to prevent staff and other patients from physical harm by Patient #2. Review of the daily staffing and census beginning 10/6/2023 through 10/19/2023 for the East Unit revealed the following: 10/6/2023- Day shift 2 nurses, 3 BHAs. Evening shift 2 nurses, 1 BHA. Night shift 2 nurses, 2 BHA’s for census of 21. Evening shift and Night shift did not meet the staff ratio goal of 1 staff to 5 patients. 10/7/2023- Day shift 2 nurses, 2 BHAs. Evening shift 2 nurses, 1 BHA. Night shift 2 nurses, 2 BHAs for census of 23. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 10/8/2023- Day shift 1 nurse, 2 BHAs. Evening shift 2 nurses, 1.5 BHAs. Night shift 2 nurses, 2 BHAs for census of 24. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 10/9/2023- Day shift 2 nurses, 2 BHAs. Evening shift 2 nurses, 2 BHAs. Night shift 2 nurses, 2 BHAs for census of 27. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 10/10/2023- Day shift 2 nurses, 4 BHAs. Evening shift 2 nurses, 3.5 BHAs. Night shift 2 nurses, 2 BHAs for census of 27. Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 10/11/2023- Day shift 2 nurses, 3 BHAs. Evening shift 2 nurses, 2 BHAs. Night shift 2 nurses, 2 BHAs for census of 25. Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 10/12/2023- Day shift 2 nurses, 2 BHAs. Evening shift 2 nurses, 2 BHAs. Night shift 2 nurses, 2 BHAs for census of 26. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 10/13/2023- Day shift 2 nurses, 2 BHAs. Evening shift 2 nurses, 3 BHAs. Night shift 1 nurse, 3 BHAs for census of 26. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 10/14/2023- Day shift 2 nurses, 3 BHAs. Evening shift 2 nurses, 1.5 BHAs. Night shift 2 nurses, 2 BHAs for census of 27. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 10/15/2023- Day shift 2 nurses, 3 BHAs. Evening shift 2 nurses, 2 BHAs. Night shift 2 nurses, 2 BHAs for census of 25. Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 10/16/2023- Day shift 2 nurses, 2 BHAs. Evening shift 2 nurses, 2 BHAs. Night shift 2 nurses, 3 BHAs for census of 27. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 10/17/2023- Day shift 2 nurses, 2 BHAs. Evening shift 2 nurses, 3 BHAs. Night shift 2 nurses, 4 BHAs for census of 24. Day shift did not meet the staff ratio goal of 1 staff to 5 patients. 10/18/2023- Day shift 2 nurses, 3 BHAs. Evening shift 2 nurses, 3 BHAs. Night shift 2 nurses, 4 BHAs for census of 27. Day and Evening shifts did not meet the staff ratio goal of 1 staff to 5 patients. 10/19/2023- Day shift 2 nurses, 2 BHAs. Evening shift 2 nurses, 3 BHAs. Night shift 2 nurses, 3 BHAs for census of 27. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. The facility failed to meet the staffing ratio goal of 1 staff member to every 5 patients on the East unit from 10/6/2023 through 10/19/2023, the entirety of Patient #2’s admission at the facility. 4. Medical record review for Patient #4 revealed an admission date of 2/7/2024 with diagnoses that included Schizoaffective disorder, Depressive type. Patient #4 admitted to the facility with a suicidal plan to cut her throat with a knife, was psychotic, and was hearing voices. Patient #4 had a history of mental illness and previous suicide attempts. On 2/8/2024, Patient #4 required Ativan (anti-anxiety medication), Benadryl (antihistamine), and Haldol (antipsychotic medication used for mental disorders) intramuscularly (IM) for agitation, and psychosis (a mental disorder characterized by a disconnection from reality). On 2/9/2024, Patient #4 required Vistaril (antihistamine) for anxiety, Risperdal (antipsychotic medication used for mental disorder) for psychosis, Celexa (antidepressant) for depression, and Trazadone (antidepressant and sedative) for sleep. Patient #4 complained of right wrist pain on 02/09/2024. An x-ray was taken of the right wrist with results documented as normal. On 2/10/2024, Patient #4 was placed on elopement precautions and unit restrictions. On 2/11/2024, a 1:40 PM nursing note revealed Patient #4 was assaulting and combative toward staff, was climbing on the nursing station and refusing to come down. Attempts to deescalate the patient were unsuccessful. Patient #4 required restraints and ultimately seclusion, where she was hitting and banging her arm on the wall of the seclusion room. Upon completion of seclusion, Patient #4 was calm and cooperative. On 2/12/2024, a 6:45 PM progress note documented, “ ...EMS [Emergency Medical Services] states patient [Patient #4] husband called the police to the facility & [and] Stated his wife’s arm was broken. Spoke with East charge nurse and she stated [Patient #4] had an xray of her right hand; and xray to hand was normal. EMS was Informed that [Patient #4] was admitted under involuntary status and [named doctor] Gave a phone order to do not transport. During this time it is believed that Husband was going to attempt to pick [Patient #4] up from front lobby or hospital ...7:10 PM [Patient #4] returns to unit, but is angry ...patient yelling and cursing; Repeatedly punching nursing station window, med [medication] window, and wall. Pt. [Patient #4] successful punched out one of nursing station windows. [Patient #4] threatening to jump in med [medication] room or nursing station station and grabbed gloves from nursing Station. [Patient #4] had to be removed from unit due to self harming behaviors and Verbal and physical attack to staff. During transport to hallway to seclusion Room [Patient #4] was kicking and scratching staff. Once placed in seclusion, [Patient #4] complained of right arm pain again ...NP [nurse practitioner] to order Stat xray ...9:47 PM Xray technician arrived to unit; informed staff that a break in ulnar [arm] is observed ...12:15 AM Ambulance on unit to transport [Pateint #4] to hospital ...” Nursing oversight failed to ensure Patient #4 was free from injury, including a fractured arm, after repeated, ongoing behaviors while admitted to the facility. Review of the daily staffing and census beginning 2/7/2024 through 2/12/2024 on the East Unit revealed the following: 2/7/2024- Day shift 1 nurse, 4 BHAs. Evening shift 2 nurses, 3 BHAs. Night shift 2 nurses, 2 BHAs for census of 26. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 2/8/2024- Day shift 2 nurses, 3 BHAs. Evening shift 2 nurses, 2 BHAs. Night shift 2 nurses, 2 BHAs for census of 25. Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 2/9/2024- Day shift 2 nurses, 3 BHAs. 2 nurses, 2 BHAs, and 1 Certified Nursing Assistant (CNA) for ½ shift, then Night shift 2 nurses, 2 BHAs for census of 21. Night shift did not meet the staff ratio goal of 1 staff to 5 patients. 2/10/2024- Day shift 2 nurses, 3 BHAs. Evening shift 2 nurses, 1.5 BHAs. Night shift 2 nurses, 1 BHA for census of 22. Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 2/11/2024- Day shift 1.5 nurses, 2 BHAs. Evening shift 1 nurse, 2 BHAs. Night shift 2 nurses, 1 BHA for census of 28. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. 2/12/2024- Day shift 2 nurses, 2 BHAs. Evening shift 2 nurses, 2.5 BHAs. Night shift 2 nurses, 2 BHAs for census of 27. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients. The facility failed to meet the staffing ratio goal of 1 staff member to every 5 patients on the East unit from 2/7/2024 through 2/12/2024 during Patient #4’s admission to the facility. 5. Observations on the North Unit on 02/21/2024 at 9:20 AM, revealed the unit was housed with patients who were high acuity (patients who required closer monitoring and interventions such as patients diagnosed with major psychoses). There were twenty (20) patients on the unit. Two (2) Behavioral Health Associates (BHAs) were present. Nineteen (19) patients required monitoring every fifteen (15) minutes. One (1) patient required monitoring every five (5) minutes. Patients were observed to be wandering all over the unit. Some patients were in the day room, some patients were in the hallway, and some patients were in group recreation. The ratio of Behavioral Health Associates (BHA) to patients was 2:20. Two nurses were charting in the nurses’ station. Observations on the South Unit on 02/21/2024 at 9:30 AM, revealed the unit housed patients with a lower acuity (Patients who required less monitoring and interventions). There were seventeen (17) patients were on the unit, one (1) BHA, two (2) Registered Nurses (RN), and one (1) Licensed Practical Nurse (LPN). 6. In an interview on 02/21/2024 at 9:50 AM, the Chief Financial Officer (CFO) reported the staffing ratio goal for direct care staff to patients is one (1) staff to five (5) patients. The staff included in that ratio included the unit registered nurses and licensed practical nurses. In an interview on 02/21/2024 at 10:05 AM, Registered Nurse (RN) #2 stated she worked as needed, primarily on the North unit. RN #2 stated the North unit had 20 beds, and the average census was sixteen (16) to twenty (20) patients. RN #2 stated it was rare that the census was fifteen (15) patients or less, and the staff mix for the North unit was usually two (2) licensed staff and two (2) or more BHAs. RN #2 stated there was sometimes only one behavior health assistant on the unit. In an interview on 02/21/2024 at 10:15 AM, RN #1 confirmed she was assigned to the North unit (high acuity patients) with a census of twenty (20) patients on the unit and a staff assignment of two (2) BHA and two (2) nurses. RN #1 stated one (1) patient was on observations every five (5) minutes, and the remaining nineteen (19) patients required observation every fifteen (15) minutes. RN #1 stated the BHAs and nurses did all the patient observations, and the patient who required observation every five (5) minutes required documentation /progress notes every two (2) hours. RN #1 stated a behavior health assistant typically attended patient group therapies. RN #1 stated that if a patient became violent or physically aggressive, staff called a code. RN #1 stated agency staff could not assist with restraining a patient or with any other activity that required hands-on-care. RN #1 confirmed she was injured by a patient while on-duty at the hospital. RN #1stated there was not sufficient staff on the units, and the units were short of staff every day. RN #1 stated the lack of sufficient staffing made it more dangerous for patients and staff. RN #1 confirmed on the day she was attacked, there were two (2) BHAs assigned to the unit and probably eighteen (18) patients on the unit. RN #1 stated it was not unusual to have only one BHA assigned to a unit. In an interview on 02/21/2024 at 10:20 AM, RN #3 stated she primarily worked on the East unit (a high acuity unit). RN #3 stated the census for the East unit was usually at its maximum of twenty-eight (28) patients, and the hospital normally staffed two (2) licensed staff and two (2) BHAs. RN #3 stated there were times when only one (1) BHA was assigned to the unit, and this happened more frequently than it should. RN #3 stated the hospital has utilized [named Agency] BHAs, but agency staff were not allowed to touch the patients. RN #3 stated her main concern was when the hospital didn’t have enough BHAs assigned to the unit, the registered nurses or licensed practical nurses had to work as BHAs. RN #3 stated this caused the licensed staff’s work to get behind. In an interview on 02/21/2024 at 10:30 AM, RN #4 stated she primarily worked the East unit. That unit was usually staffed with one (1) registered nurse, one (1) licensed practical nurse, and two (2) BHA. RN #4 stated the staff assigned to the unit included [named Agency] BHAs who could not assist with restraining patients. RN #4 stated staff often complained about not having enough BHAs. In an interview on 02/21/2024 at 10:35 AM, BHA #1 stated she was assigned all seventeen (17) patients on the unit, but she had been assigned as many as twenty (20) patients at one time. BHA #1 stated if something was going on, or there was a one to one (1:1) patient assignment, the nurses watched the other patients. BHA #1 stated the hospital needed more staff because the staff assigned to the units could not watch the patients adequately. BHA #1 stated she felt the unit was not staffed sufficiently which put both patients and staff in danger. BHA #1 stated she was aware that one (1) of the agency staff was injured by a patient, and a therapist was injured by a patient a couple of days later and sent to the hospital via ambulance due to the injury. In an interview on 02/21/2024 at 10:35 AM, RN #5 reported he primarily worked on the South unit which can have twenty (20) patients. RN #5 stated the patients on the South unit were usually there for self-harm or detoxification. RN #5 stated he primarily worked as the Charge Nurse or medication nurse for the unit. RN #5 stated unit staffing usually consisted of two (2) RNs or one (1) RN and one (1) LPN with one (1) or two (2) BHAs. RN #5 stated the hospital used agency staff to supplement staffing on the unit. In an interview on 02/21/2024 at 10:43 AM, RN #6 stated she currently worked on the West unit which held a maximum of twelve (12) patients. RN #6 stated the patients on the West unit were elderly, usually sixty (60) to eighty (80) years-old, and were diagnosed with depression or suicidal ideations. RN #6 stated the present daily census was ten (10) patients, and there was one (1) RN staffed for the West unit. RN #6 stated depending on acuity, number of fall risks, and incontinent patients, they could have one (1) certified nursing assistant (CNA) and one (1) behavior health assistant. RN #6 stated the hospital would staff with one (1) licensed nurse and one (1) certified nursing assistant or one (1) behavior health assistant if the acuity of the patients was lower. RN #6 stated she wished that the nurse/patient ratio was better. RN #6 stated she believed there was a problem with the safety of the patients and staff. RN #6 stated when there were fights between the patients, the behavior health assistants were not able to handle those incidents, and the BHAs were scared to respond to the fights. RN #6 stated the nurse workload could be overwhelming due to the lack of staffing. In an interview on 02/21/2024 at 11:00 AM, the Interim Risk Manager stated the parameters for unit staffing included three (3) or four (4) staff for every fifteen (15) patients. In an interview on 02/21/2024 at 12:20 PM, the Chief Nursing Officer (CNO) stated unit staffing assignments were completed by the Staffing Coordinator. The Staffing Coordinator, Assistant Director of Nursing, and Chief Nursing Officer reviewed the unit staffing assignments every morning. The CNO stated changes in staffing depended on the time of day, and the Unit Nurse Manager contacted the Staffing Director to get staff called in if necessary, The CNO stated the staff to patient ratio goal was 1:5 which included the registered nurses and licensed practical nurses. The CNO stated the Chief Executive Officer and Chief Financial Officer configured the census needs range based on staff to patient ratio and patient needs, but the hospital “is not sticking to either one.” The CNO confirmed it was her responsibility to provide oversight of nursing scheduling to make sure the needs of the patients were met. In an interview on 2/21/2024 at 2:05 PM, the Human Resources (HR) Director stated she had seen an increase in injuries to staff related to patient aggressive/violent episodes, and she had received an increasing number of employee concerns/complaints regarding insufficient unit staff. The HR Director stated the hospital’s goal for staffing was to have a 1:5 staff to patient ratio, depending on patient acuity. The HR Director stated the hospital used unit nurses to figure the staff to patient ratio, but the unit nurses alternated their nursing duties with patient assignment duties. The HR Director stated that neither nurses nor behavior health assistants were assigned to specific patients, and the only patient directly assigned to a specific behavior health assistant or nurse was one who required one to one monitoring. The HR Director stated patients who required monitoring every five (5) minutes were grouped with the other patients in determining the number of direct care staff to assign to the unit. The HR Director stated staff had expressed concerns to her regarding staff safety as well as their increased work caseload. In an interview on 02/21/2024 at 2:05 PM, the Director of Clinical Services stated a therapist was injured several weeks ago while conducting a Process Group. The Director of Clinical Services stated the group had started when another patient came to the group with a cup with feces in it. The patient hit the therapist and threw the feces on her. The Director of Clinical Services stated the therapist was transported to the hospital by an ambulance, but she did not recall what the therapist’s injuries were. The Director of Clinical Services stated the therapist had not returned to work since the incident. The Director of Clinical Services stated there have been multiple situations where staff had been injured while dealing with patients over the past six months. The Director of Clinical Services confirmed the hospital had room for improvement related to staffing. In an interview on 02/21/2024 at 3:45 PM, the Scheduler for nursing services stated her duty was to make staff assignments. When questioned as to whether [named hospital] had parameters related to staff/patient ratios, the Scheduler stated, “Not really.” She stated that if there was a one to one (1:1) patient observation on the unit, extra staff was called in for that unit. The Scheduler stated that if necessary, she personally worked on the units to fill in for staff needs. She stated that she was “going to work as a tech [technician] tonight due to a staff call-in.” In an interview on 02/23/2024 at 9:10 AM, the Administrator stated the unit registered nurse might be responsible for nursing care for two units at the same time, and both units were locked and divided by a hallway. In an interview on 02/23/2024 at 9:50 AM on the South unit, RN #8 reported the patient census was eighteen (18) and in addition to herself, there was one (1) behavioral health assistant on the unit. In an interview on 02/23/2024 at 9:52 AM, RN #6 stated she was the only licensed staff on the West unit. There was one (1) certified nursing assistant or behavior health assistant for eleven (11) patients.”

“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: 49645 Based on medical record review, observations and interviews, the hospital failed to ensure a Registered Nurse (RN) provided supervision and oversight to ensure the patients’ needs were met and prevent accidents and incidents. The findings included: 1. Review of medical record for Patient #2 revealed an admission date of 10/06/2023. Patient #2 was an emergency involuntary admission who was hearing voices, paranoid, very agitated, confused and a danger to self and others. Patient #2 required physical and chemical restraints on 10/06/2023 and was ordered to receive Benadry (antihistamine), Haldol (medication given to agitated patients, reduce hallucinations and delirium), Ativan (sedative; used to treat seizure disorders or anxiety) administered intramuscularly (IM). On 10/07/2023, Patient #2 was upset over involuntary status, threatening to kill self, refused PRN medication, attempted to barricade self in day room. Required physical restraint by staff for administration of as needed (PRN) medication. On 10/10/2023, Patient #2 was beating on the nurses station window and medication room window, yelling, screaming, threatening. Patient #2 assaulted a staff member. The patient required chemical and physical restraint. Patient #2 received a one (1) x (time) order for Geodon (antipsychotic used to treat mental health conditions) 20 milligrams (mg) IM every (q) 12 hours PRN agitation. Seclusion ordered. Had to be carried to the seclusion room. On 10/14/2023 and 10/15/2023, Patient #2 assaulted other patients on the unit. 2. Review of medical record for Patient #4 revealed an admission date of 02/07/2024 with a suicidal plan to cut her throat with a knife, was psychotic, and was hearing command voices. Patient #3 had a history of mental illness and previous suicide attempts. Patient #3 had poor judgement, poor insight, agitation, irritability, depressed mood, and hallucinations. The patient suffered a self-injury (broken hand) while hospitalized at this hospital. On 02/08/2024, the patient required Ativan (anti-anxiety medication), Benadryl (antihistamine), and Haldol (antipsychotic medication used for mental disorders) intramuscularly (IM) for agitation, Extrapyramidal side effects (EPS; drug-induced movement disorder) prevention, and psychosis (a mental disorder characterized by a disconnection from reality). On 02/09/2024, the patient required Vistaril (antihistamine) for anxiety, Risperdal (antipsychotic medication used for mental disorder) for psychosis, Celexa (antidepressant) for depression, and Trazadone (antidepressant and sedative) for sleep. Patient #3 complained of right wrist pain on 02/09/2024. An x-ray was taken of the right wrist with results documented as normal. On 02/10/2024, the patient was placed on elopement precautions and unit restrictions. On 02/11/2024, the patient required Geodon (antipsychotic used to treat schizophrenia and bipolar disorder) intramuscular (IM) and was placed in restraints until calm. On 02/12/2024, the patient climbed the nurses station, punched the glass and door, and was very threatening and disruptive on the unit. Risperdal (antipsychotic used to treat schizophrenia and bipolar disorder) and Celexa were increased on 02/12/2024 and she required as needed (PRN) Thorazine (antipsychotic used to treat mental illness and behavioral disoders). While in the control room, Patient #4 was observed hitting the walls and to be verbally threatening others. Patient #4’s right arm was noted to be swollen “from previous self-injury”, and her right hand was also noted to be swollen “from previous self-injury.” Order were received for transfer to an acute care hospital for evaluation. Emergency Medical Services (EMS) and Police arrived at facility at 7:45 PM on 02/12/2024. Patient #3’s husband called police, stating his wife’s arm was broken. EMS was informed the Patient’s previous x-ray was normal, patient was involuntary status, and Medical Doctor (MD) gave phone order “Do Not Transport.” Patient #4 refused to return to the unit until escorted by staff. Patient #4 returned to unit angry, yelling, cursing, repeatedly punching nurses station window, medication room window, wall. Patient #4 punched out one of nurses station windows. Patient #4 threatened to jump in the nurses station or medication room and grabbed gloves from nurses station. Patient #4 had to be removed from unit due to self-harming behaviors and verbal/physical attack on staff. During transport to seclusion room, Patient #4 was kicking and scratching herself. Once in seclusion room, Patient #4 complained of pain again in the right arm. The Nurse called the Nurse Practitioner for stat x-ray. Patient #4 continued to yell at staff and punch the walls. An X-ray was performed and Patient #4 was diagnosed with a broken arm. A verbal order was received from the Physician to transport Patient #4 to an acute care hospital. The ambulance arrived on the unit at 12:15 AM to transport Patient #4 to an acute care hospital. Patient #3 returned to hospital at 3:05 AM with a soft plaster cast on the right arm. 2. Observations on the North Unit on 02/21/2024 at 9:20 AM, revealed the unit was housed with patients who were high acuity (patients who required closer monitoring and interventions such as patients diagnosed with major psychoses). There were twenty (20) patients on the unit. Two (2) Behavioral Health Associates (BHAs) were present. Nineteen (19) patients required monitoring every fifteen (15) minutes. One (1) patient required monitoring every five (5) minutes. Patients were observed to be wandering all over the unit. Some patients were in the day room, some patients were in the hallway, and some patients were in group recreation. The ratio of Behavioral Health Associates (BHA) to patients was 2:20. Two nurses were charting in the nurses’ station. 3. Observations on the South Unit on 02/21/2024 at 9:30 AM, revealed the unit housed patients with a lower acuity (Patients who required less monitoring and interventions). There were seventeen (17) patients were on the unit, one (1) BHA, two (2) Registered Nurses (RN), and one (1) Licensed Practical Nurse (LPN). In an interview on 02/21/2024 at 9:50 AM, the Chief Financial Officer (CFO) reported the staffing ratio goal for direct care staff to patients is one (1) staff to five (5) patients. The staff included in that ratio included the unit registered nurses and licensed practical nurses. In an interview on 02/21/2024 at 10:05 AM, RN #2 stated she worked as needed, primarily on the North unit. RN #2 stated the North unit had 20 beds, and the average census was sixteen (16) to twenty (20) patients. RN #2 stated it was rare that the census was fifteen (15) patients or less, and the staff mix for the North unit was usually two (2) licensed staff and two (2) or more BHAs. RN #2 stated there was sometimes only one behavior health assistant on the unit. RN #2 stated she was unaware of who were contract employees, but she knew that contract employees were not allowed to touch the patients. In an interview on 02/21/2024 at 10:15 AM, RN #1 confirmed she was assigned to the North unit (high acuity patients) with a census of twenty (20) patients on the unit and a staff assignment of two (2) BHA and two (2) nurses. RN #1 stated one (1) patient was on observations every five (5) minutes, and the remaining nineteen (19) patients required observation every fifteen (15) minutes. RN #1 stated the BHAs and nurses did all the patient observations, and the patient who required observation every five (5) minutes required documentation /progress notes every two (2) hours. RN #1 stated a behavior health assistant typically attended patient group therapies. RN #1 stated that if a patient became violent or physically aggressive, staff called a code. RN #1 confirmed she had worked with behavior health assistants and nurses from [named Agency]. RN #1 stated agency staff could not perform “hands-on-care,” but they were counted as part of the staff/patient ratio. RN #1 stated agency staff could not assist with restraining a patient or with any other activity that required hands-on-care. RN #1 confirmed she was injured by a patient while on-duty at [named hospital]. RN #1 stated a patient was sitting on the floor as RN #1 exited the nurses’ station, and the patient bit her on the thigh. RN #1 stated there was not sufficient staff on the units, and the units were short of staff every day. RN #1 stated the lack of sufficient staffing made it more dangerous for patients and staff. RN #1 confirmed on the day she was attacked, there were two (2) BHAs assigned to the unit and probably eighteen (18) patients on the unit. RN #1 stated that one of the BHAs was reassigned to another unit which left only one behavior health assistant on the unit. RN #1 stated it was not unusual to have only one BHA assigned to a unit. In an interview on 02/21/2024 at 10:20 AM, RN #3 stated she primarily worked on the East unit (a high acuity unit). RN #3 stated the census for the East unit was usually at its maximum of twenty-eight (28) patients, and the hospital normally staffed two (2) licensed staff and two (2) BHAs. RN #3 stated there were times when only one (1) BHA was assigned to the unit, and this happened more frequently than it should. RN #3 stated the hospital has utilized [named Agency] BHAs, but agency staff were not allowed to touch the patients. RN #3 stated her main concern that was when the hospital didn not have enough BHAs assigned to the unit, the registered nurses or licensed practical nurses thad to work as BHAs. RN #3 stated this caused the licensed staff’s work to get behind. In an interview on 02/21/2024 at 10:30 AM, RN #4 stated she primarily worked the East unit. That unit was usually staffed with one (1) registered nurse, one (1) licensed practical nurse, and two (2) BHA. RN #4 stated the staff assigned to the unit included [named Agency] BHAs who could not assist with restraining patients. RN #4 stated staff often complained about not having enough BHAs. In an interview on 02/21/2024 at 10:35 AM, BHA #1 stated she was assigned all seventeen (17) patients on the unit, but she had been assigned as many as twenty (20) patients at one time. BHA #1 stated if something was going on, or there was a one to one (1:1) patient assignment, the nurses watched the other patients. BHA #1 stated the hospital needed more staff because the staff assigned to the units could not watch the patients adequately. BHA #1 stated she felt the unit was not staffed sufficiently which put both patients and staff in danger. BHA #1 stated she was aware that one (1) of the agency staff was injured by a patient, and a therapist was injured by a patient a couple of days later and sent to the hospital via ambulance due to the injury. In an interview on 02/21/2024 at 10:35 AM, RN #5 reported he primarily worked on the South unit.which can have twenty (20) patients. RN #5 stated the patients on the South unit were usually there for self-harm or detoxification. RN #5 stated he primarily worked as the Charge Nurse or medication nurse for the unit. RN #5 stated unit staffing usually consisted of two (2) RNs or one (1) RN and one (1) LPN with one (1) or two (2) BHAs. RN #5 stated the hospital used agency staff to supplement staffing on the unit. In an interview on 02/21/2024 at 10:43 AM, RN #6 stated she currently worked on the West unit which held a maximum of twelve (12) patients. RN #6 stated the patients on the West unit were elderly, usually sixty (60) to eighty (80) years-old, and were diagnosed with depression or suicidal ideations. RN #6 stated the present daily census was ten (10) patients, and there was one (1) RN staffed for the West unit. RN #6 stated depending on acuity, number of fall risks, and incontinent patients, they could have one (1) certified nursing assistant (CNA) and one (1) behavior health assistant. RN #6 stated the hospital would staff with one (1) licensed nurse and one (1) certified nursing assistant or one (1) behavior health assistant if the acuity of the patients was lower. RN #6 stated she wished that the nurse/patient ratio was better. RN #6 stated she believed there was a problem with the safety of the patients and staff, and she felt that the facility should have security on the units. RN #6 stated when there were fights between the patients, the behavior health asistants were not able to handle those incidents, and the BHAs were scared to respond to the fights. RN #6 stated the hospital got panic buttons last week after a therapist was attacked by a patient, but the hospital was still working to “get the bugs out” of the staff using the panic buttons. RN #6 stated the nurse workload could be overwhelming due to the lack of staffing. In an interview on 02/21/2024 at 11:00 AM, the Interim Risk Manager stated the parameters for unit staffing included three (3) or four (4) staff for every fifteen (15) patients. In an interview on 02/21/2024 at 12:20 PM, the Chief Nursing Officer (CNO) stated unit staffing assignments were completed by the Staffing Coordinator. The Staffing Coordinator, Assistant Director of Nursing, and Chief Nursing Officer reviewed the unit staffing assignments every morning. The CNO stated changes in staffing depended on the time of day, and the Unit Nurse Manager contacted the Staffing Director to get staff called in if necessary, The CNO stated the staff to patient ratio goal was 1:5 which included the registered nurses and licensed practical nurses. The CNO confirmed a patient kicked a behavioral health assistant several weeks ago, and she investigated the incident. The CNO stated she did not know how many patients the behavioral health assistant was assigned at the time of the incident, but it was typical to have only one (1) behavioral health assistant assigned to each unit on the second shift. The CNO stated agency staff were required to participate in the facility mandatory training, but agency staff did not participate in the physical restraining of the patients. The CNO stated if a patient needed to be restrained, staff would call a code to handle violent/aggressive situations on the unit. The CNO stated agency staff would be utilized to keep their eyes on the other patients. When asked if agency staff received training for de-escalation, seclusion, and restraints, the CNO stated, “I am pretty sure they [agency staff] have been trained in Handle-with-Care/de-escalation and Seclusion/Restraints.” The CNO stated the Chief Executive Officer and Chief Financial Officer configured the census needs range based on staff to patient ratio and patient needs, but the hospital “is not sticking to either one.” The CNO confirmed it was her responsibility to provide oversight of nursing scheduling to make sure the needs of the patients were met. The CNO stated it was the responsibility of the House Supervisor to ensure that new hires were properly trained before they were allowed to provide care to patients. The CNO stated De-escalation Training and Restraint/Seclusion Training was not currently mandatory for agency staff prior to unit assignment. In an interview on 2/21/2024 at 2:05 PM, the Human Resources (HR) Director stated there was no formal process for monitoring agency staff for psychiatric work experience, or training that was mandatory for [named hospital] staff prior to beginning direct patient care. The staff educator provided agency staff with orientation as a direct care provider, including Handle-with-Care/de-escalation training. The HR Director stated if agency staff had not completed Hands-on-Care/de-escalation training, they could not provide hands-on care for patients. When questioned as to who handled monitoring of agency staff to ensure they did not provide hands on care, the HR Director stated, “The charge nurse monitored agency staff to ensure they didn’t provide hands-on care to patients unless they had completed the Handle-with-Care training.” The HR Director stated she had seen an increase in injuries to staff related to patient aggressive/violent episodes, and she had received an increasing number of employee concerns/complaints regarding insufficient unit staff. The HR Director stated the hospital’s goal for staffing was to have a 1:5 staff to patient ratio, depending on patient acuity. The HR Director stated the hospital used unit nurses to figure the staff to patient ratio, but the unit nurses alternated their nursing duties with patient assignment duties. The HR Director stated that neither nurses nor behavior health assistants were assigned to specific patients, and the only patient directly assigned to a specific behavior health assistant or nurse was one who required one to one monitoring. The HR Director stated patients who required monitoring every five (5) minutes were grouped with the other patients in determining the number of direct care staff to assign to the unit. The HR Director stated staff had expressed concerns to her regarding staff safety as well as their increased work caseload. In an interview on 02/21/2024 at 2:05 PM, the Director of Clinical Services stated a therapist was injured several weeks ago while conducting a Process Group. The Director of Clinical Services stated the group had started when another patient came to the group with a cup with feces in it. The patient hit the therapist and threw the feces on her. The Director of Clinical Services stated the therapist was transported to the hospital by an ambulance, but she did not recall what the therapist’s injuries were. The Director of Clinical Services stated the therapist had not returned to work since the incident. The Director of Clinical Services stated there have been multiple situations where staff had been injured while dealing with patients over the past six months. The Director of Clinical Services confirmed the hospital had room for improvement related to staffing. In an interview on 02/21/2024 at 2:20 PM, the Nurse Educator stated nursing leadership handled the orientation for agency staff. The Nurse Educator stated she maintained copies of staff training records but did not maintain training records for agency staff. The Nurse Educator stated she and Human Resources had dual responsibilities to ensure that direct care staff had mandatory/required competencies prior to being assigned to work on a unit. The Nurse Educator stated nursing leadership and Human Resources had dual responsibilities to ensure that agency staff had the required competencies prior to unit assignment. In an interview on 02/21/2024 at 3:45 PM, the Scheduler for nursing services stated her duty was to to make staff assignments. When questioned as to whether [named hospital] had parameters related to staff/patient ratios, the Scheduler stated, “Not really.” In an interview on 02/23/2024 at 9:10 AM, the Administrator stated that agency staff did not provide hands-on-care or physical restraints and did not touch the patient at all if it was related to Handle-with-Care/de-escalation situations. The Administrator stated agency staff could not provide physical assistance in dealing with combative/aggressive patients or physically hold patients for injections. The Administrator stated that was a hospital rule and not the staffing agency’s rule, but the hospital communicated this rule with the agency. The Administrator stated agency staff were not required to have seclusion and restraint, Handle-with-Care, or de-escalation training prior to assigment to a unit. The Administrator stated the unit registered nurse might be responsible for nursing care for two units at the same time, and both units were locked and divided by a hallway. In an interview on 02/23/2024 at 9:50 AM on the South unit, RN #8 reported the patient census was eighteen (18) and in addition to herself, there was one (1) behavioral health assistant on the unit. In an interview on 02/23/2024 at 9:52 AM, RN #6 stated she was the only licensed staff on the West unit. There was one (1) certified nursing assistant or behavior health assistant for eleven (11) patients.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 49645 Based on policy review, document review, medical record review and interview, the facility failed to ensure medications were administered per physician order for 7 of 7 (Patients #5, 6, 7, 8, 9,10 and 11) patients reviewed with medication variances. The findings included: 1. Review of the facility’s “MEDICATION ADMINISTRATION AND DOCUMENTATION” policy (reviewed 3/2023) revealed, “...All ordered medications administered to patients will be documented on the Medication Administration Record...Check patient’s Medication Administration Record (MAR) to ensure that the order is accurate...1. Verify patient 2. Verify medication 3. Verify dosage 4. Verify route 5. Verify frequency 6. Verify stop date 7. Note any cautionary statements...” 2. Review of the facility’s Incident Report log beginning 9/1/2023 through 2/21/2024 revealed the following: September 2023- 2 patient related Medication Variances. October 2023- 1 patient related Medication Variances. November 2023- 1 patient related Medication Variances. December 2023- 1 patient related Medication Variances. January 2024- 0 patient related Medication Variances. February 2024- 2 patient related Medication Variances. 3. Medical record review for Patient #5 revealed an admission date of 9/20/2023 with diagnoses that included Major Depressive Disorder. Review of the September 2023 MAR revealed Zyprexa (used to treat certain mental/mood disorders) 7.5 milligrams (mg) daily (9:00 AM). The Zyprexa dose on 9/29/2023 was given in the evening, approximately 9:00 PM, instead of 9:00 AM as ordered. 4. Medical record review for Patient #6 revealed an admission date of 9/19/2023 with diagnoses that included Bipolar disorder with psychosis. Review of 9/30/2023 physician orders revealed Trazadone (antidepressant) 50 mg by mouth every bedtime as needed. Review of the September 2023 Medication Administration Record (MAR) revealed Trazadone 50 mg documented as given on 9/30/2023 at 8:00 PM. Review of the facility’s Incident Report log revealed Tramadol (opioid analgesic) 50 mg was given instead of the ordered Trazadone on 9/30/2023 at 8:00 PM. 5. Medical record review for Patient #7 revealed an admission date of 10/4/2023 with diagnoses that included Schizoaffective Disorder, Bipolar type. Review of 10/10/2023 physician orders revealed “Start Celexa [used to treat Depression] 5mg p.o. [by mouth] daily” Review of October 2023 MAR revealed Celexa 5 mg was signed out as given on 10/11/2023 through 10/13/2023. Review of the facility’s Incident Report log for Patient #7 revealed, “Patient had an order to receive Celexa 5mg PO [by mouth] and did not receive it. Patient brought this medication from home and it has not been administered due to the medication being unable to be located in the med [medication] room, although nursing staff signed off on the MAR that they gave this medication to the patient” 6. Medical record review for Patient #8 revealed an admission date of 11/2/2023 with diagnoses that included Schizoaffective Disorder, Bipolar type. Review of 11/2/2023 Medication Reconciliation orders revealed Trazodone 50 mg PO every (Q) bedtime (HS) as needed (prn). Review of Patient #8’s November MAR revealed on 11/8/2023 Trazodone 50 mg was administered at 1:45 PM. Not at bedtime as ordered. 7. Medical record review for Patient #9 revealed an admission date of 12/25/2023 with diagnoses that included Schizoaffective disorder, Bipolar type. Review of the facility’s Incident Report log documentation revealed while housed on the East Unit on 12/26/2023, Patient #9 identified herself as another patient to the nurse administering medications. Patient #9 received a dose of Trazadone 50 mg that was not prescribed to her. 8. Medical record review for Patient #10 revealed an admission date of 1/27/2024 with diagnoses that included Schizophrenia. Review of 2/1/2024 medication orders written at 10:50 AM revealed “Vistaril [used to treat anxiety and tension] 50 mg PO every 6 hours prn; 1st dose now”. Review of Patient #10’s February 2024 MAR revealed on 2/1/2024 Vistaril 50 mg was documented as given at 2:30 PM, 3 hours and 40 minutes after the order was written to be given “now”. 9. Medical record review for Patient #11 revealed an admission date of 1/9/2024 with diagnoses that included Major Depressive disorder with psychosis. Review of 2/3/2024 physician orders revealed Haldol (antipsychotic) 15 mg (1/2 tab [tablet]) by mouth twice daily. Review of February 2024 MAR revealed Haldol 15 mg (1/2 tab) twice daily was documented as given on 2/4/2024 at 9:00 AM and 9:00 PM. Review of the facility’s Incident Report log revealed a whole tablet (15 mg) was given on 2/4/2024 at the 9:00 PM dose instead of the ½ tablet as ordered. In an electronic correspondance (email) on 4/10/2024, the Risk Manager verified the medication variances for Residents #5, 6, 7, 8, 9,10 and 11.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 49645 Based on policy reivew, document review, observation and interview, the hospital failed to maintain sufficient staff to ensure safe and adequate care for for 2 of 4 (Patient #2 and #4) sampled patients reviewed. The findings included: 1. Review of the facility’s “ASSIGNMENT OF NURSING STAFF” policy (reviewed 4/18/23) revealed, “ ...It is the policy of this facility to maintain a staffing level, which supports safe and effective care for each clinical program ...1. Nursing Services use a 24-hour staffing pattern. a. Nurse is assigned to each shift. b. Nurse provides supervision on the shifts ...d. Staffing increases with acuity and changes in census, assessed by the Nurse and/or Supervisor and communicated to Nursing Administration ...” 2. Review of the facility’s “RN [Registered Nurse]” job description revealed, “ ...Responsible for providing professional nursing care to patients with a positive, empathetic, and professional attitude to foster a supportive and therapeutic environment. Recognize that patient safety is a top priority ...” Review of the facility’s “BEHAVIORAL HEALTH ASSOCIATE 1” job description revealed, “ ...Responsible for providing personal care services to patients at the facility under the direction of clinical or nursing leadership ...Assist in providing a safe, secure and comfortable environment for patients, significant others and staff ...” 3. Medical record review for Patient #2 revealed an admission date of 10/6/2023 with diagnoses that included Schizoaffective Disorder, Depressive type. Patient #2 was an emergency involuntary admission who was hearing voices, paranoid, very agitated, confused and a danger to self and others. Patient #2 was housed on the East Unit. (Patient #2 was discharged from the facility on 10/19/2023). On 10/07/2023, Patient #2 became upset over involuntary status, threatening to kill self, refused as needed (PRN) medication, and attempted to barricade self in day room. Patient #2 required physical restraint by staff for administration of a PRN medication. On 10/10/2023, Patient #2 became upset again after meeting with the patient advocate. Patient #2 began beating on the nurse’s station window and medication room window, yelling, screaming, and threatening to slap a staff member. Patient #2 required chemical and physical restraint, with seclusion ultimately ordered. Review of a 10/15/2023 Psychiatry Progress Note documented, “ ...easily influenced and provoked. Reported as assaulting another patient on yesterday ...Behaviors remain unpredictable ...” Nursing oversight failed to prevent Patient #2 from endangering himself through behaviors, and failed to prevent staff and other patients from physical harm by Patient #2. Review of the facility’s daily census and staffing documentation revealed the facility failed to meet the staffing ratio goal of 1 staff member to every 5 patients on the East unit from 10/6/2023 through 10/19/2023, the entirety of Patient #2’s admission at the facility. 4. Medical record review for Patient #4 revealed an admission date of 2/7/2024 with diagnoses that included Schizoaffective disorder, Depressive type. Patient #4 admitted to the facility with a suicidal plan to cut her throat with a knife, was psychotic, and was hearing voices. Patient #4 had a history of mental illness and previous suicide attempts. On 2/8/2024, Patient #4 required Ativan (anti-anxiety medication), Benadryl (antihistamine), and Haldol (antipsychotic medication used for mental disorders) intramuscularly (IM) for agitation, and psychosis (a mental disorder characterized by a disconnection from reality). On 2/9/2024, Patient #4 required Vistaril (antihistamine) for anxiety, Risperdal (antipsychotic medication used for mental disorder) for psychosis, Celexa (antidepressant) for depression, and Trazadone (antidepressant and sedative) for sleep. Patient #4 complained of right wrist pain on 02/09/2024. An x-ray was taken of the right wrist with results documented as normal. On 2/10/2024, Patient #4 was placed on elopement precautions and unit restrictions. On 2/11/2024, a 1:40 PM nursing note revealed Patient #4 was assaulting and combative toward staff, was climbing on the nursing station and refusing to come down. Attempts to deescalate the patient were unsuccessful. Patient #4 required restraints and ultimately seclusion, where she was hitting and banging her arm on the wall of the seclusion room. Upon completion of seclusion, Patient #4 was calm and cooperative. On 2/12/2024, a 6:45 PM progress note documented, “ ...EMS [Emergency Medical Services] states patient husband called the police to the facility & [and] Stated his wife arm was broken. Spoke with East charge nurse and she stated Patient had an xray of her right hand; and xray to hand was normal. EMS was Informed that patient was admitted under involuntary status and [named doctor] Gave a phone order to do not transport. During this time it is believed that Husband was going to attempt to pick patient up from front lobby or hospital ...7:10 PM Patient returns to unit, but is angry ...patient yelling and cursing; Repeatedly punching nursing station window, med [medication] window, and wall. Pt. [Patient #4] successful punched out one of nursing station windows. Patient threatening To jump in med room or nursing station station and grabbed gloves from nursing Station. Patient had to be removed from unit due to self harming behaviors and Verbal and physical attack to staff. During transport to hallway to seclusion Room patient was kicking and scratching staff. Once placed in seclusion, Patient complained of right arm pain again ...NP [nurse practitioner] to order Stat xray ...9:47 PM Xray technician arrived to unit; informed staff that a break in ulnar is observed ...12:15 AM Ambulance on unit to transport patient to hospital ...” Nursing oversight failed to ensure Patient #4 was free from injury, including a fractured arm, after repeated, ongoing behaviors while admitted to the facility. Review of the facility’s daily census and staffing documentation revealed the facility failed to meet the staffing ratio goal of 1 staff member to every 5 patients on the East unit from 2/7/2024 through 2/12/2024 during Patient #4’s admission to the facility. 5. Observations on the North Unit on 02/21/2024 at 9:20 AM, revealed the unit was housed with patients who were high acuity (patients who required closer monitoring and interventions such as patients diagnosed with major psychoses). There were twenty (20) patients on the unit. Two (2) Behavioral Health Associates (BHAs) were present. Nineteen (19) patients required monitoring every fifteen (15) minutes. One (1) patient required monitoring every five (5) minutes. Patients were observed to be wandering all over the unit. Some patients were in the day room, some patients were in the hallway, and some patients were in group recreation. The ratio of Behavioral Health Associates (BHA) to patients was 2:20. Two nurses were charting in the nurses’ station. Observations on the South Unit on 02/21/2024 at 9:30 AM, revealed the unit housed patients with a lower acuity (Patients who required less monitoring and interventions). There were seventeen (17) patients were on the unit, one (1) BHA, two (2) Registered Nurses (RN), and one (1) Licensed Practical Nurse (LPN). 6. In an interview on 02/21/2024 at 9:50 AM, the Chief Financial Officer (CFO) reported the staffing ratio goal for direct care staff to patients is one (1) staff to five (5) patients. The staff included in that ratio included the unit registered nurses and licensed practical nurses. In an interview on 02/21/2024 at 10:05 AM, RN #2 stated there was sometimes only one behavior health assistant on the unit. In an interview on 02/21/2024 at 10:15 AM, RN #1 stated there was not sufficient staff on the units, and the units were short of staff every day. RN #1 stated the lack of sufficient staffing made it more dangerous for patients and staff. In an interview on 02/21/2024 at 10:20 AM, RN #3 stated she primarily worked on the East unit (a high acuity unit).RN #3 stated the census for the East unit was usually at its maximum of twenty-eight (28) patients, and the hospital normally staffed two (2) licensed staff and two (2) BHAs. RN #3 stated there were times when only one (1) BHA was assigned to the unit, and this happened more frequently than it should. In an interview on 02/21/2024 at 10:30 AM, RN #4 stated she primarily worked the East unit. That unit was usually staffed with one (1) registered nurse, one (1) licensed practical nurse, and two (2) BHA. RN #4 stated the staff assigned to the unit included [named Agency] BHAs who could not assist with restraining patients. RN #4 stated staff often complained about not having enough BHAs. In an interview on 02/21/2024 at 10:35 AM, BHA #1 stated she was assigned all seventeen (17) patients on the unit, but she had been assigned as many as twenty (20) patients at one time. BHA #1 stated if something was going on, or there was a one to one (1:1) patient assignment, the nurses watched the other patients. BHA #1 stated the hospital needed more staff because the staff assigned to the units could not watch the patients adequately. BHA #1 stated she felt the unit was not staffed sufficiently which put both patients and staff in danger. In an interview on 02/21/2024 at 10:43 AM, RN #6 stated she currently worked on the West Unit. RN #6 stated she wished that the nurse/patient ratio was better. RN #6 stated she believed there was a problem with the safety of the patients and staff. RN #6 stated when there were fights between the patients, the behavior health assistants were not able to handle those incidents, and the BHAs were scared to respond to the fights. RN #6 stated the nurse workload could be overwhelming due to the lack of staffing. In an interview on 02/21/2024 at 11:00 AM, the Interim Risk Manager stated the parameters for unit staffing included three (3) or four (4) staff for every fifteen (15) patients. In an interview on 02/21/2024 at 12:20 PM, the Chief Nursing Officer (CNO) stated unit staffing assignments were completed by the Staffing Coordinator. The Staffing Coordinator, Assistant Director of Nursing, and Chief Nursing Officer reviewed the unit staffing assignments every morning. The CNO stated changes in staffing depended on the time of day, and the Unit Nurse Manager contacted the Staffing Director to get staff called in if necessary, The CNO stated the staff to patient ratio goal was 1:5 which included the registered nurses and licensed practical nurses. The CNO stated the Chief Executive Officer and Chief Financial Officer configured the census needs range based on staff to patient ratio and patient needs, but the hospital “is not sticking to either one.” The CNO confirmed it was her responsibility to provide oversight of nursing scheduling to make sure the needs of the patients were met. In an interview on 2/21/2024 at 2:05 PM, the Human Resources (HR) Director stated she had seen an increase in injuries to staff related to patient aggressive/violent episodes, and she had received an increasing number of employee concerns/complaints regarding insufficient unit staff. The HR Director stated the hospital’s goal for staffing was to have a 1:5 staff to patient ratio, depending on patient acuity. The HR Director stated the hospital used unit nurses to figure the staff to patient ratio, but the unit nurses alternated their nursing duties with patient assignment duties. The HR Director stated staff had expressed concerns to her regarding staff safety as well as their increased work caseload. In an interview on 02/21/2024 at 3:45 PM, the Scheduler for nursing services stated her duty was to make staff assignments. When questioned as to whether [named hospital] had parameters related to staff/patient ratios, the Scheduler stated, “Not really.” She stated that if there was a one to one (1:1) patient observation on the unit, extra staff was called in for that unit. The Scheduler stated that if necessary, she personally worked on the units to fill in for staff needs. She stated that she was “going to work as a tech [technician] tonight due to a staff call-in.” In an interview on 02/23/2024 at 9:10 AM, the Administrator stated the unit registered nurse might be responsible for nursing care for two units at the same time, and both units were locked and divided by a hallway. Refer to A-0392.”