Knoxville Center for Behavioral Medicine

“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: 51389 Based on review of current facility policies, medical record review, review of facility documentation and interviews, the hospital’s Governing Body failed to have processes and policies in place to protect each patient’s right to be free from abuse, failed to ensure a safe environment for 2 patients (Pt #9 and Pt #11) and failed to report an assault by Pt #10 to the proper state authorities. §482.12 Condition of Participation: Governing Body not met. The governing body failed in being responsible for the conduct of the hospital in relation to the potential for violent patient behaviors not addressed with policies and processes in place to promote safety of all patients. The governing body failed to ensure the required physician oversight of the medical providers on staff were sufficient to the challenges of the patient population. The failure to protect patients and staff from violent behaviors of patients in mental health crisis resulted in the facility placing 2 patients in an Immediate Jeopardy situation, when Patient #10 with a known history of violent behavior, did not have a treatment plan to address this threat and did not have an investigation and action plan developed after assaulting 2 fellow patients, in 2 separate incidents, 3 days apart. The hospital’s non-compliance placed all patients being treated on Pt. #10’s unit in an Immediate Jeopardy situation which created the need for immediate action. The findings include: The facility failed to have a process or policy in place for identification, communication and escalation of “potential” violent patients to active violent patients. A lack of a process was demonstrated by the intake department when not communicating to staff, providers, and administration information related to Pt #10’s recent violent behaviors prior to admission. There was a narrative note placed in the medical record only. This failure was also demonstrated by staff and the medical provider not knowing of any proactive processes to take other than de-escalation. The facility failed to have policies for management of a violent patient-to-patient interaction. This was demonstrated by interviews with staff and Pt #10’s medical provider when they stated they were not aware of any type of protocols for a violent patient-to-patient interaction. The facility failed to ensure a safe environment for the patients and the governing body failed to act after a violent patient injured two fellow patients (Pt #9 and Pt #11) in two separate events. The governing body also failed to ensure physician oversight of Pt #10. This is evidenced by Pt #10, admitted with a history of violent behaviors, being placed on the routine standard observations of every 15 minutes checks. The standard observations continued after the first assault to Pt #11on 6/24/2025. The second assault happened on 6/27/2025 at approximately 12:30 PM. Pt #10’s treatment plan regarding medications or observation status did not change until 6/27/2025 at 10:57 AM, when a medication dosage was changed. Facility reports were reviewed and revealed the governing body did not take immediate action after either assault to investigate, identify contributing factors, and provide a plan of correction to ensure patient safety. Refer to A-0049 and a-0144.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 51389 Based on review of facility policies, medical record review, review of facility documentation, review of video footage and interviews, the hospital failed to protect each patients’ rights to be free from abuse and failed to ensure a safe environment for 2 patients (#9 and #11) of 13 patients reviewed. §482.13 Condition of Participation: Patient Rights not met. The hospital must protect and promote each patient’s rights, including the right to receive safe care. This failure resulted in the facility placing 2 patients in an Immediate Jeopardy situation, when Patient #10 with a known history of violent behavior, did not have a treatment plan to address this threat and did not have an investigation and action plan developed after assaulting 2 fellow patients, in 2 separate incidents, 3 days apart. The hospital’s non-compliance placed all patients being treated on Pt. #10’s unit in an Immediate Jeopardy situation which created the need for immediate action. The findings include: Pt #9, Pt #10, and Pt #11 were patients admitted to the facility to be treated on the same unit. Pt #10 was admitted with known violent behaviors and this information was not disseminated to the appropriate nurses, treatment team or administration. On 6/24/2028, Pt #10 assaulted Pt #11 and it resulted in Pt #11 going to a hospital emergency department (ED) for complaints of a headache, chest pain, and “bump on her head.” Pt #10’s Treatment Plan did not have any changes in his observation status or routine medications at that time. On 6/27/2025 at 10:57 AM, the medical provider (NP #1) increased Pt #10’s Clozaril ( a medication to treat Schizophrenia). On 6/27/2025 at approximately 12:30 PM, Pt #10 assaulted Pt #9. The assault resulted in Pt #9 being sent to an ED with a facial laceration and fractures of the cheek bone and bones surround the eye. Pt #9 was returned to the facility. Interview with the medical provider, NP #1, revealed the medical provider was not aware of Pt #10’s violent history initially, she talked to Pt #10’s mother and was told Pt #10 recently started Clozaril and she thought it could be causing the violent behaviors in Pt #10. Further interview revealed after the first assault on 6/24/2025, the medical provider stated she had reviewed Pt #10’s medications and discontinued the Clozaril. However, review of Pt #10’s medication regimen revealed the Clozaril was not discontinued until 6/27/2025. The facility failed to provide a safe environment by not acting on the knowledge of a new patient (#10) with a recent history of violence and they did not take immediate action after either assault to investigate, identify contributing factors, and provide a plan of correction. Refer to A-0144”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 51389 Based on review of medical record, review of facility documentation and interviews, the hospital failed to address critical issues related to a previous history of violence and a violent event that occurred at their facility. They failed to create a comprehensive admission treatment plan and failed to keep a treatment plan updated based on significant changes during the inpatient stay for 1 patient (Pt #10) out of 13 reviewed. §482.61 Condition of Participation: Special medical record requirements for psychiatric hospitals were not met. The facility failed at the responsibility of maintaining a comprehensive and ongoing treatment plan for one patient, Pt #10, who was admitted with a known history of violent behavior. The violent history was noted in the medical record during the intake process on 6/22/2025, but it was not acknowledged or addressed in the Psychiatric Evaluation by the Provider on 6/23/2025. This failure resulted in 2 patients (Pt #11, and Pt #9) being assaulted by Pt #10 in 2 separate incidents, 3 days a part. Pt #10 was placed on standard observation on admission with no elevation in interventions for his history of violence. Pt #10 had demonstrated lack of impulse control, and his behavior quickly escalated to violence. On 6/24/2025, Pt #10 assaulted Pt #11 causing an injury to her head which prompted a transfer to the ED (Emergency Department). Following the first assault, Pt #10’s observation status did not change and the treatment plan did not change until the morning of 6/27/2025, the fifth day of his stay. In the afternoon of 6/27/2025, Pt #10 assaulted Pt #9, causing major injuries which prompted a transfer of Pt #9 to the ED. The hospital did not provide a treatment plan for Pt #10 that addressed all aspects of his behaviors. The hospital’s non-compliance placed all patients being treated on Pt. #10’s unit in an Immediate Jeopardy situation, which created the need for immediate action. The findings include: Pt #9, Pt #10 and Pt #11 were patients admitted to the facility to be treated on the same unit. Pt #10 was admitted with known violent behaviors and this information was not disseminated to the treatment team. The problem of Pt #10’s recent violence toward his mother, leading to his arrest, was not assessed or addressed in his treatment plan. On 6/24/2028, Pt #10 assaulted Pt #11 and it resulted in Pt #11 going to a hospital emergency department (ED) for complaints of a headache, chest pain, and “bump on her head.” Pt #10’s Treatment Plan did not have any changes in his observation status or routine medications at that time. On 6/27/2025 at approximately 12:30 PM, Pt #10 assaulted Pt #9. The assault resulted in Pt #9 being sent to an ED with a facial laceration and fractures of facial bones. Interview with the medical provider, NP #1, revealed the medical provider was not aware of Pt #10’s violent history initially when the Treatment Plan was developed. The facility failed to provide a safe environment by not acting on the knowledge of a new patient (#10) with a recent history of violence and they did not take immediate action after either assault to investigate, identify contributing factors, and provide a plan of correction. Refer to A-0144 and A-1640”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 51389 Based on review of facility policy, medical record review, review of facility documentation, review of video footage and interviews, the hospital’s Governing Body failed to protect patients’ right to be free from abuse, failed to have oversight of a medical provider to ensure safe and quality care was delivered, and failed to ensure a safe environment for 2 patients (#9 and #11) of 13 patients reviewed. The findings include: Review of the hospital policy, “Patient Rights,” revised 5/26/2024, 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 facility from neglect; from physical, verbal and emotional abuse...All hospital staff, medical staff members and contracted agency staff performing patient care activities shall observe these patients’ rights...” Medical record review revealed Pt #10 was admitted on 6/22/2025 at 3:23 PM under involuntary commitment with Psychosis (loss of contact with reality) and Schizophrenia. Medical record review of a Narrative Note dated 6/22/2025 at 5:06 PM, revealed the intake department noted “...received call from [mother] stating she is patient’s [Pt #10] conservator...Patient was recently incarcerated after assaulting his mother...said he could not return to the mother’s residence...” Medical record review of a Psychiatric Evaluation dated 6/23/2025 at 12:08 PM, revealed Pt #10 was only oriented to person “...has history of schizophrenia, 30 plus hospitalizations...denies SI...slow, loud and nonsensical...thought content is delusions...patient presents with a slow and disorganized thought process, affect is labile with inappropriate laughter noted throughout the assessment. He exhibits delusional thinking, expressing the belief that he is at the facility to win the championship in basketball...patient describes his mood as “great,” this is incongruent with his overall presentation...speech is slow but loud and often nonsensical...frequently stares into space...questions must be repeated multiple times due to impaired attention and processing...” Review of the plan of care developed in tandem with the medical provider, Nurse Practitioner (NP) #1 on the second day after admission, dated 6/23/2025, for Pt #10 revealed the following: -Zoloft 100 mg (milligram) daily for mood -Clozaril (for Schizophrenia) 25 mg twice a day -Klonopin (for agitation) 1 mg at bedtime -Haldol (for psychotic episodes) 200 mg IM (intramuscular) every 3 weeks -Every 15-minute checks -Encouraging daily participation in groups -Collateral information with family Medical record review of a Social Worker’s Psychosocial Assessment dated 6/24/2025 at 12:07 PM, revealed “...patient [Pt #10]...responding to internal stimuli...laughing out loud and talking to himself...does endorse AVH [audio/visual hallucinations]...” Further review revealed “Patient was recently arrested for assault.” Medical record review revealed Pt #11 was admitted on 6/20/2025 at 12:52 AM under involuntary commitment with SI (Suicidal Ideation) and Psychosis. Medical record review of a Social Worker’s Narrative Note dated 6/24/2025 at 2:51 PM, revealed Pt #11 was transported to a hospital Emergency Department (ED) and medically discharged from the ED to her home. Review of a facility report document dated 6/24/2025 at 6:27 PM, revealed “...from 6:27 PM-6:30 PM Pt #10 walked into [Pt #11’s] room, attacked her and then walked out of the room. The panic button hit. At 6:30 PM he [Pt #10] ran back into the room and attacked her. Staff pulled him off her. [Pt #11] placed into the hospital, visible knot on the side of her head.” The investigation and plan of action for prevention “in the future” section of the report revealed “Patient [Pt# 11] went to the hospital and discharged home. [Pt #10] was placed in seclusion and was later removed [from seclusion]. Provider [Nurse Practitioner #1] assessed both patients and adjusted [Pt #10’s] medications.” (Note: From medical record review, there were no changes made to Pt #10’s routine psychiatric medications until 6/27/2025). Medical record review of the Nurses Assessment dated 6/24/2025 at 8:22 PM, revealed “...Patient [Pt #10] attacked a patient [#11] unprovoked, and it took three staff members to pull him off and take him to seclusion...Pt #10 was placed in seclusion and was “very aggressive, cussing, speaking gibberish, completely psychotic...” Medical record review of Provider Notes dated 6/25/2025 at 10:20 PM, revealed “Patient is observed responding to internal stimuli, frequently pacing the unit while talking to himself. He presents with impulsive and unpredictable behavior. Last night, he entered a female patient’s room without permission and physically assaulted her...placed in seclusion for safety. No behavioral disturbances have been reported today. However, the patient remains delusional and disoriented to situation, stating he believes he is here for a sporting event.” Continued review revealed no changes were made in Pt #10’s treatment plan. Medical record review of a Provider Note, by NP #1, dated 6/27/2025 at 10:57 AM, revealed Pt #10 “... observed in day area responding to internal stimuli. He was seen laughing loudly, he reported seeing a man sprinting down the hallway. Patient continues to present as unpredictable, with episodes of intermittent aggression. Due to impulsivity, Depakote 250 mg twice daily has been initiated...” The provider (NP #1) changed the treatment plan with an order to increase Clozaril to 25 mg in the morning and 50 mg at bedtime for Schizophrenia. Medical record review revealed Pt #9 was admitted on 6/22/2025 at 5:42 PM under voluntary agreement with SI. Medical record review of Nurses Notes dated 6/27/2025 at 12:58 PM (2 hours after treatment plan changes), revealed Pt #9 “...has been hit by another patient...911 pick up at 12:55 and she was sent to [a local hospital] ED.” Medical record review of Nurses Assessment dated 6/27/2025 at 1:48 PM, revealed Pt #10 was getting ready for lunch when “...he randomly walked up to a female patient [Pt #9] and punched her and then tried to attack another patient. Patient was placed in seclusion then left with the [local police department].” Medical record review of hospital ED records for Pt #9 dated 6/27/2025 at 4:04 PM, revealed a CT scan (Computed Tomography) of Maxillofacial (facial) area showed “...complex fracture [fracture though the whole cheek bone]...periorbital edema...surrounding subcutaneous emphysema [air trapped under the skin] and traumatic fluid in the left [cheek area]...displaced fracture of lateral and inferior orbital walls [fracture where the ends of the bone do not meet-fracture of the side and inside the eye bone walls]...” Continued review of the ED records revealed Pt #9 was returned to the facility. Review of facility report documentation dated 6/27/2025 at 12:32 PM, revealed “...getting ready for lunch- [Pt #9] coming from her room when she was punched by [Pt #10]. While getting cleaned up [Pt #9] had a seizure. Transferred to [local ED] and [Pt #10] was placed in seclusion and was transferred to [police department]. Continued review revealed the investigation and plan of action for prevention in the future section of the report was blank. There was no follow up documented. An interview on 7/14/2025 at 12:30 PM, with NP #1 revealed she remembered Pt #9, Pt 10, and Pt #11. NP #1 stated Pt #10 was there with a history of Schizophrenia, and he had ingested Kratom (herbal supplement which can cause stimulant associated symptoms) which induced Psychosis. NP #1 revealed she was not initially aware Pt #10 had a history of assaulting his mother. NP #1 stated it is typically the responsibility of the social worker to call the next of kin or POA (power of attorney) to get collateral information (information from other sources such as family or friends). She stated “ideally it should be done within 24 hours of admission.” NP #1 did talk to Pt #10’s mother at “some point” but did not remember when. NP #1 revealed the mother said Pt #10 had recently been placed on Clozaril and was questioning if this is what had changed his recent behaviors...” NP #1 stated after the event on 6/24/2025, she reviewed Pt #10’s medications and she discontinued the Clozaril because it might be increasing his violent behavior. Interview revealed she did not change the level of his observation, “It should have been changed to line of sight...really probably 1:1 within arm’s reach...but sometimes this does make them more agitated...” NP #1 stated all patients are on at least every 15-minute checks. Interview continued and NP #1 stated there was no hospital policies to give guidance related to increasing frequency of observational checks. An interview on 7/14/2025 at 1:05 PM, with the Interim Quality Director, revealed the previous Interim Assistant CNO (Chief Nursing Officer) was at the facility when the second assault to Pt #9 occurred. “The Assistant CNO went to the unit after it happened...she wrote up a root causes analysis for the event...I can’t say there is a process for patient-to-patient violence...” She stated she recently was given the responsibility for incident reports, and she was not sure whose responsibility it was prior to this due to the recent changes in their administration. Interview confirmed there was no follow up to the incident report for Pt #10’s second assault. An interview on 7/17/2025 at 12:15 PM, with the Medical Director revealed he had oversight of all the Nurse Practitioners, “...I come 2 times a month and spend all day doing Treatment Team Meetings, reviewing notes, and cosigning the Admission Psychological Assessment and Discharge Summaries. They are able to call me anytime... When I see something weird, I call them to ask questions...We only have to cosign 20% of their documentation...I did review [Pt #10’s] chart and he would have been on assault precautions...if the patient is not showing signs and symptoms we may not change the standard observation of every 15 minutes...it is hard to make patients 1:1 observation...most of the patients are violent and they get medications...” Interview clarified Assault Precautions were geared to the staff to not see patients alone. In summary, the governing body and medical providers failed to ensure a safe environment for Pt’s #9 and #11. The governing body failed to address the lack of physician oversight. Pt #10 had a known history of violence on admission and he remained on routine-standard observation of every 15-minute checks, including after the first assault on 6/24/2025. There were no changes made in Pt #’10 treatment plan with regards to routine medications until 6/27/2025. Pt #10’s recent history of violence was not assessed on his initial psychiatric evaluation, although the social worker had made note of this on day of admission. It was revealed in an interview with NP #1 that Pt #10’s mother told her he was started on a new medicine, Clozaril, prior to his admission, and she was worried this was causing his violent behaviors. NP #1 revealed she reviewed his medications after the first assault and discontinued the Clozaril, but it was not discontinued. On 6/27/2025 at 10:57 AM, the Clozaril dosage was increased. Facility reports were reviewed which revealed the governing body did not take immediate action after either assault to investigate, identify contributing factors, and provide a plan of correction to provide a plan of correction to ensure patient safety.”

“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: 51389 Based on review of facility policies, medical record review, review of facility documentation, review of video footage and interviews, the hospital failed to ensure a safe environment for 2 patients (#9 and #11) of 13 patients reviewed. The findings include: Review of hospital Policy “Patient Rights” revised 5/26/2024, 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 facility from neglect; from physical, verbal and emotional abuse...All hospital staff, medical staff members and contracted agency staff performing patient care activities shall observe these patients’ rights...” Medical record review revealed Pt #10 was admitted to the facility on 6/22/2025 at 3:23 PM, under an involuntary commitment with Psychosis (loss of contact with reality) and Schizophrenia. Medical record review of a Narrative Note dated 6/22/2025 at 5:06 PM, revealed “...received call from [mother] stating she is patient’s [Pt #10] conservator...Patient was recently incarcerated after assaulting his mother...said he could not return to the mother’s residence... Apparently, officers have said if he returns to mother’s home, they will rearrest him...” Medical record review of the Nursing Assessment dated 6/23/3035 at 12:08 AM, revealed Pt #10 “...with every 15 minute observations...pacing unit...pleasant...denies SI/HI/VH [suicidal ideations/homicidal ideation/visual hallucinations]...states auditory hallucinations are quiet...laughing and talking with self...patient endorses anxiety...” Medical record review of the Psychiatric Evaluation dated 6/23/2025 at 12:08 PM, revealed Pt #10 was only oriented to person “...has history of schizophrenia, 30 plus hospitalizations...denies SI...slow, loud and nonsensical...thought content is delusions...patient presents with a slow and disorganized thought process, affect is labile with inappropriate laughter noted throughout the assessment. He exhibits delusional thinking, expressing the believe that he is at the facility to win the championship in basketball...patient describes his mood as “great,” this is incongruent with his overall presentation...speech is slow but loud and often nonsensical...frequently stares into space...questions must be repeated multiple times due to impaired attention and processing...” Review of the plan of care developed in tandem with the Nurse Practitioner (NP #1), on the second day after admission, dated 6/23/2025, for Pt #10 revealed the following: -Zoloft 100 mg (milligram) daily for mood -Clozaril (for Schizophrenia) 25 mg twice a day -Klonopin (for agitation) 1 mg at bedtime -Haldol (for psychotic episodes) 200 mg IM (intramuscular) every 3 weeks -Every 15-minute checks -Encouraging daily participation in groups -Collateral information with family Medical record review of a Social Worker’s Psychosocial Assessment dated 6/24/2025 at 12:07 PM, revealed “...patient [Pt #10] presents with pleasant affect...struggling to carry on conversation...seen on the unit responding to internal stimuli...laughing out loud and talking to himself...does endorse AVH [audio/visual hallucinations]...” Further review revealed “Patient was recently arrested for assault.” Medical record review revealed Pt #11 was admitted to the facility on 6/20/2025 at 12:52 AM, under an involuntary commitment with SI (Suicidal Ideation) and Psychosis. Medical record review of a Social Worker’s Narrative Note dated 6/24/2025 at 2:51 PM, revealed Pt #11 was transported to a hospital Emergency Department (ED), medically discharged from the ED to her home. Review of a facility report document dated 6/24/2025 at 6:27 PM, revealed “...from 6:27 PM-6:30 PM Pt #10 walked into [Pt #11’s] room, attacked her and then walked out of the room. The panic button hit. At 6:30 PM he [Pt #10] ran back into the room and attacked her. Staff pulled him off her. [Pt #11] placed into the hospital, visible knot on the side of her head.” The investigation and plan of action for prevention in the future section of the report revealed “Patient [Pt# 11] went to the hospital and discharged home. [Pt #10] was placed in seclusion and was later removed [from seclusion]. Provider [Nurse Practitioner #1] assessed both patients and adjusted [Pt #10’s] medications.” (Note: From medical record review, there were no changes made to Pt #10’s routine psychiatric medications until 6/27/2025 ). Review of a video recording of the assault to Pt #11 dated 6/24/2025, verified the event occurred. In the video, Pt #10 ran into Pt #11’s room, started swinging his arms and pushed her on the bed. Staff came in and separated them and both patients went out of the room. Approximately 30 seconds later, Pt #11 runs into her room and Pt #10 is following. He pushed her on to the bed and was hitting her. Four staff are seen running into the room to pull Pt #10 off Pt 11. Pt #10 is escorted out the door. Medical record review of Medication Administration Report dated 6/24/2025 at 7:00 PM, revealed the following medications were given to Pt #10 for psychotic agitation: diphenhydramine (antihistamine and can be used to decrease anxiety) 50 mg (milligram) IM (intramuscular), haloperidol lactate (antipsychotic) 5 mg IM, and lorazepam (to treat anxiety) 2 mg IM. Medical record review of a Nurses Assessment dated 6/24/2025 at 8:22 PM, revealed “...Patient [Pt #10] attacked another patient [#11] unprovoked, and it took three staff members to pull him off and take him to seclusion...” [Pt #10] was placed in seclusion and was “very aggressive, cussing, speaking gibberish, completely psychotic...” Medical record review of a Nursing Assessment dated 6/25/2025 at 2:58 PM, revealed Pt #10 continued to pace the floors and laughing out loud at times “...sometimes he will clap really loud and start to make random noises, he has moments of clarify for a brief moment but then starts speaking gibberish...He received PO [by mouth] B52 [medication cocktail] for agitation protocol due to becoming aggressive when asked by staff to quiet down, he was upsetting other patients during this episode...” Medical record review of a Provider Note dated 6/25/2025 at 10:20 PM, revealed “Patient is observed responding to internal stimuli, frequently pacing the unit while talking to himself. He presents with impulsive and unpredictable behavior. Last night, he entered a female patient’s room without permission and physically assaulted her. As a result, he was administered a B52 (Benadryl, Haldol, Ativan) and placed in seclusion for safety. No behavioral disturbances have been reported today. However, the patient remains delusional and disoriented to situation, stating he believes he is here for a sporting event.” Continued review revealed no changes were made in Pt #10’s treatment plan. Medical record review of the Social Worker Narrative Note dated 6/26/2025 at 9:36 AM-12:45 PM, revealed collateral contact was made with Pt #10’s mother “...Mom explained what patient has been doing before admission. Pt has been smoking THC [primary compound in marijuana] and that it makes patient completely out of his mind. Pt has been in and out of outpatient for the last year...was discharged from [a facility for emergency psychiatric assessment and treatment] for months... [Pt #10’s] mother reported he assaulted her the week prior [to this admission]...Mother states she has never seen patient in this bad of a state and that he has never been aggressive...” Medical record review of the Provider Note dated 6/27/2025 at 10:57 AM, revealed Pt #10 “... observed in day area responding to internal stimuli. He was seen laughing loudly. When asked about the reason he stated he saw a man running track at Tennessee High...he reported seeing a man sprinting down the hallway. Patient continues to present as unpredictable, with episodes of intermittent aggression. Due to impulsivity, Depakote [mood stabilizer] 250 mg twice daily has been initiated...” The provider (NP #1) changed the treatment plan with an order to increase Clozaril to 25 mg in the morning and 50 mg at bedtime for Schizophrenia. Medical record review revealed Pt #9 was admitted to the facility on 6/22/2025 at 5:42 PM under voluntary agreement with SI. Medical record review of a Nurses Note dated 6/27/2025 at 12:58 PM (2 hours after treatment plan changes), revealed Pt #9 “...has been hit by another patient...911 pick up at 12:55 and she was sent to [a local hospital] ED.” Medical record review of the Nurses Assessment dated 6/27/2025 at 1:48 PM, revealed Pt #10 was getting ready for lunch when “...he randomly walked up to a female patient [Pt #9] and punched her and then tried to attack another patient. Patient was placed in seclusion then left with [the local police department].” Medical record review of Treatment Plan dated 6/27/2025 at 1:45 PM, revealed Pt #10 was discharged to the police department. Medical record review of ED records for Pt #9 dated 6/27/2025 at 4:04 PM, revealed a CT scan (Computed Tomography) of Maxillofacial (facial) area was completed and it showed “...left zygomaticomaxillary complex fracture ] cheek bone fracture]...periorbital edema [fluid surrounding the eye] extending along the left cheek and surrounding subcutaneous emphysema [air trapped beneath the skin] and traumatic fluid in the left zygomatic area [cheek bone]...displaced fracture of lateral and inferior orbital walls..[fracture where the ends do not meet].” Continue review of the ED records revealed Pt #9 was returned to the facility. Review of facility report documentation dated 6/27/2025 at 12:32 PM, revealed “...getting ready for lunch- [Pt #9] coming from her room when she was punched by [Pt #10]. While getting cleaned up [Pt #9] had a seizure. Transferred to [local ED] and [Pt #10] was placed in seclusion and was transferred to [police department]. Continued review revealed the investigation and plan of action for prevention in the “future” section of the report was blank. Further review revealed there was no follow up documention. Review of a video recording of the second assault dated 6/27/2025, verified the event occurred. Pt #10 punched Pt #9 in the left side of her face at 12:27 PM. An interview on 7/14/2025 at 12:30 PM, with NP #1 revealed she remembered Pt #9, Pt 10 and Pt #11. NP #1 stated Pt #10 was there with a history of Schizophrenia, and he had ingested Kratom (herbal supplement which can cause stimulant associated symptoms) which induced Psychosis. NP #1 revealed she was not initially aware of Pt #10’s recent history of assaulting his mother. NP #1 stated it is typically the responsibility of the social worker to call the next of kin or POA (power of attorney) to get collateral information (information from other sources such as family or friends)...”ideally it should be done within 24 hours of admission.” NP #1 stated she did talk to Pt #10’s mother at “some point” but did not remember when. NP #1 revealed the mother said Pt #10 had recently been placed on Clozaril and was questioning if this is “...what had changed his recent behaviors...” NP #1 stated after the event on 6/24/2025, she reviewed Pt #10’s medications and she discontinued the Clozaril because it might be increasing his violent behavior. NP #1 stated she did not change the level of his observation. “It should have been changed to line of sight...really probably 1:1 within arm’s reach...but sometimes this does make them more agitated...” NP #1 stated all patients are on at least every 15-minute checks and stated there was not any hospital policies giving guidance on this. An interview on 7/14/2025 at 1:05 PM, with the Interim Quality Director, revealed the previous Interim Assistant CNO (Chief Nursing Officer) was at the facility when the second assault to Pt #9 occurred and stated “the Assistant CNO went to the unit after it happened...she wrote up a root causes analysis for the event...I can’t say there is a process for patient-to-patient violence...” She revealed she recently was given the responsibility for incident reports and she was not sure whose responsibility it was prior to this due to the recent changes in their administration. The interview confirmed there was no follow up to the incident report for Pt. #10’s second assault, commited on Pt #9. An interview on 7/14/2025 at 1:10 PM, with Licensed Practical Nurse (LPN) #1 revealed she was the nurse for both Pt #9 and Pt #10 on 6/27/2025. She stated “They were getting ready to go to lunch. [Pt #9] was sitting at the wall waiting. There was a lot of noise, and I saw [Pt #10] go in front of [Pt #9] and he punched her on the right side...Her blood pressure was low at 60/47. After a short time, she responded properly to questions. I had to place a steri-strip [strip of tape like substance to hold a laceration closed] on her head and then ice. We sent her to the emergency room.” An interview on 7/14/2025 at 2:00 PM, with House Supervisor (HS #1) revealed she was there for the first assault on Pt #11. “...The event relay went off [activation of a panic button] and when I got to the unit, 3 people were getting him [Pt #10] off [Pt #11]...[Pt #11] had a pump knot on her head. She [Pt #11] went to the ED, and I was told she was discharged from there...We notified the AOC [Administration on Call].” An interview on 7/17/2025 at 12:15 PM, with the Medical Director, revealed he had oversight of all the Nurse Practitioners, “...I come 2 times a month and spend all day doing Treatment Team Meetings, reviewing notes, and cosigning the Admission Psychological Assessment and Discharge Summaries. They are able to call me anytime... When I see something weird, I call them to ask questions...We only have to cosign 20% of their documentation...I did review [Pt #10’s] chart and he would have been on assault precautions...if the patient is not showing signs and symptoms we may not change the standard observation of every 15 minutes...it is hard to make patients 1:1 observation...most of the patients are violent and they get medications...” Interview clarified Assault Precautions were geared to let the staff know to not see patients alone. In summary, the provider and governing body failed to ensure a safe environment for Pt #9 and Pt #11. Pt #10 had a known history of violence on admission and he was placed on the normal protocol for every patient for “every 15-minute” observations on admission. There were no “assault protocols” initiated. After the first assault to Pt #11, there were no changes made to Pt #10’s Treatment Plan regarding routine medications and Pt #10 remained on every 15-minute observations. It was revealed in an interview with NP #1, Pt #10’s mother told her he was started on a new medicine, Clozaril, prior to his admission and she [the mother] was worried this is what was causing his violent behaviors. NP #1 revealed she reviewed his medications after the first assault and discontinued the Clozaril, but review of the medication orders revealed it was not discontinued. On 6/27/2025 at 10:57 AM, the Clozaril dosage was increased. Facility reports were reviewed and revealed the governing body did not take immediate action after either assault to investigate, identify contributing factors, and provide a plan of correction to ensure patient safety.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 51389 Based on review of facility policies, medical record review, review of video footage and interviews, the hospital failed to implement seclusion per policy for 1 patient (#10) of 13 patients reviewed. The findings include: Review of hospital policy, “Restraint or Seclusion Use,” revised on 3/10/2025, revealed the purpose of the policy is to “...provide guidelines for the appropriate use of restraint, and seclusion in the hospital setting to ensure the safety and well being of patients and staff while complying with applicable regulations...Scope...applies to all hospital personnel, including but no limited to physicians, nurses, social workers, mental health professionals, and support staff who are involved in the care of patients who may require restrain or seclusion. Restraint initiation is restricted to Physicians, Licensed Independent Practitioner [LIP], Registered Nurses [RN’s], and Licensed Practical Nurses [LPNs]...in accordance with TNDOMHSAS guidelines for Mental Health Hospitals. Application of restraints is restricted to Physicians, LIP’s, RNs, LPNs, Certified Nursing Assistants, and Mental Health Technicians [MHTs]. Other roles involved in direct care that may respond to assist in patient de-escalation receive training in the facility’s de-escalation certification program prior to responding or participating in such an event...A thorough and accurate record must be kept of the circumstances leading to the use of restraint or seclusion, the duration, and the monitoring during its application. The includes the reason for restraint, the type of restraint used, and the outcome...” Medical record review revealed Pt #10 was admitted to the facility on 6/22/2025 at 3:23 PM under involuntary commitment with Psychosis and Schizophrenia. Medical record review of the Nurses Assessment dated 6/24/2025 at 8:22 PM, revealed “Patient [#10] attacked another patient [#11] unprovoked, and it took three staff members to pull him off and her and take him to seclusion...” Pt #10 was placed in seclusion and was “very aggressive, cussing, speaking gibberish, completely psychotic...” Medical record review of Provider Notes dated 6/26/2025 at 3:05 PM, revealed “...patient [#10] pacing the hallway, calm...cooperative. Thoughts remain disorganized and delusional...talking and laughing as though responding to people not present...” Medical record review of Nurses Assessment dated 6/27/2025 at 1:48 PM, revealed “...getting ready for lunch when [Pt #10] randomly walked up to a female patient and punched her and then tried to attack another patient...Patient was placed in seclusion then left with [the police]...” Medical record review of the Treatment Plan dated 6/27/2025 at 1:45 PM, revealed Pt #10 was discharged to the police department. Review of a video recording of the second assault dated 6/27/2025, verified the event occurred. Pt #10 punched Pt #9 in the left side of her face at 12:27 PM. After the assault, Pt #10 was escorted to the seclusion room at 12:49 PM, by a security officer (SO #1). The door was opened by SO #1 and Pt #10 entered the room. At 12:53 PM, SO #1 closes the door and locks the seclusion room. The video showed there were no employees sitting in the ante room for observation, but Pt #10 was checked by staff walking to the window to make an observation at 1:01 PM, and 1:12 PM. At 1:38 PM, the medical provider came to the door and appeared to be talking to Pt #10. At 1:40 PM, SO #1 enters the ante room to the isolation room and opened the seclusion room door. An interview on 7/14/2025 at 11:09 AM, with SO #1, confirmed he placed Pt #10 into the seclusion room. He stated the nurse makes the decision, but he “did not remember which nurse asked him to do that.” SO #1 stated he does training on how to put restraints on and off and he also stated he had CPI training (Crisis Prevention Intervention - teaches people how to de-escalate people and manage crisis). SO #1 revealed he was not aware the policy stated “Application of restraints is restricted to Physicians, LIP’s, RNs, LPNs, Certified Nursing Assistants, and Mental Health Technicians...” An interview on 7/14/2025 at 11:15 AM, with the Interim Director of Quality, revealed the security department does not get a class on application of restraints, “...They are required to do CPI though...” She was present during SO #1’s interview and she reviewed the policy and validated it does not include application by a security officer. She agreed SO #1 was working outside of his scope of practice. In summary, the hospital’s “Restraint and Seclusion Policy” revealed “...Application of restraints is restricted to Physicians, LIP’s, RNs, LPNs, Certified Nursing Assistants, and Mental Health Technicians [MHTs]. Other roles involved in direct care that may respond to assist in patient de-escalation...” The security office did not follow hospital policy and acted out of his scope of practice.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 51389 Based on review of medical records, review of video footage, review of facility documentation and interviews, the hospital failed to have a comprehensive admission treatment plan and failed to keep a treatment plan updated based on significant changes during the inpatient treatment for 1 patient (Pt #10) out of 13 patients reviewed. The findings include: Medical record review revealed Pt #10 was admitted on 6/22/2025 at 3:23 PM under involuntary commitment with Psychosis (loss of contact with reality) and Schizophrenia. Medical record review of an Intake Narrative Note dated 6/22/2025 at 5:06 PM, revealed “Received call from [mother] stating she is patient’s conservator...Patient was recently incarcerated after assaulting mother...said he could not return to the mother’s residence. Mother reports patient had been at a group home, but the group home is not a good place, and she does not want him to go back there. Apparently, officers have said if he returns to mother’s home they will rearrest him...” Medical record review of a Nursing Assessment dated 6/23/3035 at 12:08 AM, revealed Pt #10 “...with every 15 minute observations...pacing unit...pleasant...visible in milieu...denies SI/HI/VH [suicidal ideations/homicidal ideation/visual hallucinations]...states auditory hallucinations are quiet...laughing and talking with self...patient endorses anxiety...” Medical record review of a Psychiatric Evaluation by the medical provider, Nurse Practitioner (NP) #1 dated 6/23/2025 at 12:08 PM, revealed Pt #10 was only oriented to person. “...has history of schizophrenia, 30 plus hospitalizations, was at [emergency psychiatric facility] last month...denies SI...slow, loud and nonsensical...thought content is delusions...[disorganized speech]...patient presents with a slow and disorganized thought process, affect is labile with inappropriate laughter noted throughout the assessment. He exhibits delusional thinking, expressing the believe that he is at the facility to win the championship in basketball...patient describes his mood as ‘great,’ this is incongruent with his overall presentation...speech is slow but loud and often nonsensical...frequently stares into space...questions must be repeated multiple times due to impaired attention and processing...” The plan of care included the following: *Zoloft 100 mg (milligram) (medication for depression) daily *Clozaril 25 mg (medication for Schizophrenia) twice a day *Klonopin 1 mg (medication for agitation) at bedtime *Haldol 200 mg (for Psychosis) IM (intramuscular) every 3 weeks *Every 15-minute checks *Encouraging daily participation in groups *Collateral information with family Medical record review of a Social Worker’s Psychosocial Assessment dated 6/24/2025 at 12:07 PM, revealed “...patient [Pt #10] presents with pleasant affect...struggling to carry on conversation...seen on the unit responding to internal stimuli...laughing out loud and talking to himself...does endorse AVH [audio/visual hallucinations]...” Further review revealed “Patient was recently arrested for assault.” Medical record review of a Psychiatric Treatment Plan Meeting Notes dated 6/24/2025 at 1:10 PM, revealed a problem listed as “...risk for other directed violence related to aggression, reported attempt to harm others, threats to harm others...” There were no goals or interventions associated with this assessed problem added to the Treatment Plan. Medical record review revealed Pt #11 was admitted on 6/20/2025 at 12:52 AM under involuntary commitment with SI (Suicidal Ideation) and Psychosis. Medical record review of a Social Worker’s Narrative Note dated 6/24/2025 at 2:51 PM, revealed Pt #11 was transported to a hospital Emergency Department (ED) and medically discharged from the ED to her home. Review of facility report documentation dated 6/24/2025 at 6:27 PM, revealed “...from 6:27 PM-6:30 PM Pt #10 walked into [Pt #11’s] room, attacked her and then walked out of the room...at 6:30 PM he [Pt #10] ran back into the room and attacked her. Staff pulled him off her. [Pt #11] placed into the hospital, visible knot on the side of her head.” The investigation and plan of action for prevention “in the future” section of the report revealed “...Provider [NP #1] assessed both patients and adjusted [Pt #10’s] medications.” (Note: From medical record review, there were no changes made to Pt #10’s routine psychiatric medications until 6/27/2025). Medical record review of a Provider Note dated 6/25/2025 at 10:20 AM, revealed Pt #10 was still responding to internal stimuli while talking to self and pacing in the halls. “He presents with impulsive and unpredictable behavior. Last night he entered a female patient’s room without permission and physically assaulted her. As a result, he was administered [a medication cocktail] and placed in seclusion for safety. No behavioral disturbances have been reported today...However, the patient remains delusional and disoriented to situation, stating he believes he is here for a sporting event...” Continued review revealed no changes were made in Pt #10’s Treatment Plan. Medical record review of a Social Worker Narrative Note dated 6/26/2025 at 9:36 AM- 12:45 PM, revealed contact was made with Pt #10’s mother. “Mom explained what patient has been doing before admission. Pt has been smoking THC [marijuana] and that it makes patient completely out of his mind. Pt has been in and out of outpatient for the last year...” Pt #10’s mother reported he assaulted her the week prior [to admission on 7/22/2025]. “...Mother states she has never seen patient in this bad of a state and that he has never been aggressive...” Medical record review of a Provider Note dated 6/26/2025 at 3:05 PM, revealed “...patient pacing the hallway, calm...cooperative. Thoughts remain disorganized and delusional...talking and laughing as though responding to people not present...staff reports no behavior issues and has been interacting with peers without any issues...Continue plan of care...” Medical record review of a Provider Note by NP #1 dated 6/27/2025 at 10:57 AM, revealed “Patient observed in day area responding to internal stimuli. He was seen laughing loudly. When asked about the reason he stated he saw a man running track at Tennessee High...he reported seeing a man sprinting down the hallway. Patient continues to present as unpredictable, with episodes of intermittent aggression. Due to impulsivity, Depakote 250 mg [mood stabilizer] twice daily has been initiated...” The provider also changed the treatment plan by to increasing Clozaril to 25 mg in the morning and 50 mg at bedtime for Schizophrenia. Medical record review revealed Pt #9 was admitted to the facility on 6/22/2025 at 5:42 PM under voluntary agreement with SI. Medical record review of a Nurses Note dated 6/27/2025 at 12:58 PM (2 hours after treatment plan changes), revealed Pt #9 “...has been hit by another patient [Pt #10]...911 pick up at 12:55 and she was sent to [a local hospital] ED.” Medical record review of a Nursing Psychiatric Treatment Plan dated 6/27/2025 at 1:45 PM, for Pt. #10, revealed a problem listed as “...risk for other directed violence related to aggression, reported attempt to harm others, threats to harm others...” There were no goals or interventions provided to address this assessment. Medical record review of a Nurses Assessment dated 6/27/2025 at 1:48 PM, revealed Pt #10 was getting ready for lunch when “...he randomly walked up to a female patient [Pt #9] and punched her and then tried to attack another patient. Patient was placed in seclusion then left with [the local police department].” Medical record review of a hospital ED record for Pt #9 dated 6/27/2025 at 4:04 PM, revealed a CT scan (Computed Tomography) of Maxillofacial (facial) area showed “...complex fracture [fracture though the whole cheek bone]...displaced fracture of lateral and inferior orbital walls [fracture where the ends of the bone do not meet-fracture of the side and inside the eye bone walls]...” Continued review of the ED records revealed Pt #9 was returned to the facility. Review of facility report documentation dated 6/27/2025 at 12:32 PM, revealed “...getting ready for lunch- [Pt #9] coming from her room when she was punched by [Pt #10]. While getting cleaned up [Pt #9] had a seizure. Transferred to [local ED] and [Pt #10] was placed in seclusion and was transferred to [police custody]. Continued review revealed the investigation and plan of action for prevention in the “future” section of the report was blank. An interview on 7/14/2025 at 12:30 PM, with NP #1 revealed she remembered Pt #9, Pt 10, and Pt #11. NP #1 stated Pt #10 was there with a history of Schizophrenia, and he had ingested Kratom (herbal supplement which can cause stimulant associated symptoms) which induced Psychosis. NP #1 revealed she was not initially aware of Pt #10’s recent history of assaulting his mother. NP #1 stated she did talk to Pt #10’s mother at “some point” but did not remember when. NP #1 stated she did not change the level of his observation following the assault committed by Pt #10. “It should have been changed to line of sight...really probably 1:1 within arm’s reach...but sometimes this does make them more agitated...” In summary, the hospital failed to protect 2 patients from harm by not assessing and providing Pt #10 a Treatment Plan that included his known history of violence on admission. After the first assault on 6/24/2025, the Treatment Plan was not adjusted for 3 days. Pt #10 was admitted with “every 15-minute observations” standard for most patient admissions. After the first assault, the observation status was not changed. In an interview with NP #1, she revealed Pt #10’s observations “...should have been changed to line of sight...really probably 1:1 within arm’s reach...” The hospital’s non-compliance of not having an adequate Treatment Plan to address his history of violent behaviors and the lack of ongoing assessments and timely interventions for Pt #10, caused harm to 2 patients.”

“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: 51389 Based on review of the facility’s Nursing Supervisor Job Competency, review of the staffing grids, review of staffing schedules and interviews, the facility failed to ensure adequate staffing of licensed nurses for 2 of the 3 facility’s patient care units. The findings include: Review of the facility’s Nursing Supervisor Job Competency (no date) revealed the nursing supervisors role was to “...Provide oversight of nursing care during the shift; shows competency in making staffing decisions, managing contract staff shifts; Manages assignments of staff; Provides leadership during emergency events; responds timely and provides oversight of response team, facilitates de-briefing with staff and patients; Completes a thorough shift handoff at change of shift; Provides other duties as assigned with standing duties of role...” Review of staffing grids showed the following: 7/10/2025 - 6:45 AM-7:00 PM for A1 - a Behavioral Health Unit with a census of 22 patients. The staffing grid required 2 nurses, Registered Nurse (RN) or Licensed Practical Nurse (LPN). Review of the scheduled staff revealed there was 1 LPN, and the House Supervisor covering for the open second nurse position. There were 3 Behavioral Health Technicians (BHT) on duty. 7/10/2025 - 6:45 PM-7:00 AM for A2 - a Behavioral Health Unit with a census of 15 patients. The staffing grid required 2 nurses. Review of the scheduled staff revealed there was 1 RN, and the House Supervisor covering for the open second nurse position. There were 2 BHT on duty. 7/11/2025 - 6:45 AM-7:00 PM for the A1 unit with a census of 22 patients. The staffing grid required 2 nurses. Review of the scheduled staff revealed there was 1 LPN, and the House Supervisor covering for the open second nurse position. There were 2 BHT on duty. 7/15/2025 - 6:45 AM-7:00 PM for the A2 unit with a census of 21 patients. The staffing grid required 2 nurses. Review of the scheduled staff revealed there was 1 LPN, and the House Supervisor was covering for the second nurse. There were 2 BHT on duty. During an interview on 7/17/2025 at 2:00 PM, RN #1 confirmed the House Supervisors were pulled from their designated position to cover open staff positions. RN #1 stated there were staffing vacancies on the previous and upcoming schedules. Interview continued and RN #1 confirmed the House Supervisors are pulled from the unit they are covering for emergencies, to assist with admissions, provide breaks for other nurses, and to complete staffing for the next shift. During an interview on 7/17/2025 at 2:15 PM, LPN #1 confirmed there were times she had been the only nurse on the unit when the House Supervisor (filling in for the second nurse opening) had to leave the unit due to their other duties. During an interview on 7/17/2025 at 2:20 PM, RN #2 confirmed the House Supervisor role included providing lunch breaks for other units, staffing, responding to unit and patient care emergencies and providing agency nursing sign-in access to the medication storage bins. Interview confirmed the House Supervisor, when filling in for an opening in the schedule, frequently had to be off the unit when assisting with these duties. RN #2 stated lately the House Supervisor had been included in the staffing schedule with 1 LPN and the House Supervisor covering as the second nurse on the unit. RN #2 confirmed when the House Supervisor left the unit, there was only 1 nurse to provide care to all the patients. During an interview on 7/17/2025 at 2:30 PM, the Staffing Coordinator confirmed “...sometimes the House Supervisors may have to go into staffing.” She stated the staffing grids were based on census and this was used for scheduling. The Staffing Coordinator revealed the facility did not have a Chief Nursing Officer or a Nurse Manager at this time, so she worked with the Chief Executive Officer (CEO) and the Assistant Vice President when staffing. During a telephone interview on 7/17/2025 at 3:30 PM, RN #3 revealed the House Supervisor role on night shift was different than the day shift. She stated they “...checked on all the units once they had received report...On nights it was not uncommon to be pulled into staffing...” Interview continued and RN #3 revealed, when on duty as the House Supervisor, she would assign herself to the “middle unit” and tell the staff to call the house supervisor phone if they needed her. The interview revealed the facility does not routinely have a security officer and frequently the House Supervisor would have to assist with patient behaviors. If there were patients in the intake admission, the House Supervisor had to assist with those patients. RN #3 revealed her impression that patients recognized when there was not enough staff on the units, and they were more prone to act out. During an interview on 7/17/2025 at 2:40 PM, the CEO confirmed the facility had a new Chief Nursing Officer starting on Monday (7/21/2025). He confirmed there were times the facility had to pull the House Supervisors in to staff open positions on the schedule.”