Oceans Behavioral Hospital of Pasadena

“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: 38015 Based on record review and interview, the facility failed to ensure nursing performed accurate ongoing patient assessments, as shown by inconsistent documentation of a patient’s skin assessment (Patient #1). More specifically, for the majority of Patient #1’s stay, his daily nursing assessments documentation were inconsistent, showing that skin was normal, but bruises were present, with no explanation or description of the bruises. Findings included: Review of facility policy #AS-01 titled “Assessment Process: Inpatient”, last revised 2/1/26, showed that the Admit Nursing Assessment includes a physical review of symptoms. It also showed that an RN will assess a patient a minimum of every 12 hours. Record review of Patient #1’s clinical records showed the following: 79-year-old male admitted to facility on 3/24/26 due to aggression and agitation. He was oriented to self only and could not provide meaningful information about himself throughout his stay. On 4/9/26 he was transferred to HCA Houston Southeast Hospital emergency room for a higher level of care due to electrolyte imbalance. Once there, he was diagnosed with bleeding in his brain. Admit Nursing Assessment on 3/24/26 showed skin was warm and dry, no bruises. Multidisciplinary nursing notes by RN Staff G, signed on 3/24/26 at 8:12 pm, showed that at 2:00 pm that day, the patient became aggressive and hit a staff member. He was restrained and given the emergency medications Geodon 10 mg and Benadryl 25 mg intramuscularly, then put in the seclusion room. Multidisciplinary nursing notes signed and dated 3/24/26 at 4:59 pm from RN Staff I, showed “Patient have a skin bruise per assessment but no open wound”. It was unclear when and how the patient sustained the bruise. There was no explanation or description as to the location, type, age, appearance, or size. 3/25/26 Nursing Progress Notes for both the morning and evening shifts showed skin was normal, but there were bruises present. Again, there was no explanation when the patient sustained the bruise and no description as to the location, type, age, appearance, or size. On 3/25/26 in the late evening, the patient became aggressive again and grabbed another patient by the neck. He was restrained again and given the emergency medications Geodon 10 mg and Benadryl 25 mg intramuscularly, then put in the seclusion room. Review of all subsequent nursing skin assessments for both morning and evening shifts up until 4/8/26 showed skin was normal, but, bruises were present with no explanations. Nursing notes for the 4/8/26 morning shift (signed and dated five days later on 4/14/26 at 11:52 am), showed “Patient right eye area observed with a bruise under the eyelid. The night nurse reported it was observed on her shift this morning and was documented.” Nursing notes for 4/8/26 evening shift showed “ ...black eye with tiny cut to left eye.” Nursing notes for 4/9/26 morning shift showed “ ...left bruised eye but no open wound”. Nursing notes on 4/9/26 at 5:53 am by RN Staff #H showed “DC (discharge) skin assessment completed, patient would not allow staff to see back and bottom ...”. There was no mention of eye bruising. X-rays of face were taken on 4/9/26 at 11:57 am; there were no fractures identified. Nursing notes for 4/9/26 by RN Staff #G (signed and dated 4/14/26 at 6:46 pm), showed “HCA Bayshore (hospital) contacted requesting an update ...nurse to nurse report received stating patient will be admitted for evaluation and management of head bleed”. Nursing notes for 4/9/26 by RN Staff #G (signed and dated on 4/14/26 at 6:54 pm), showed the patient was transferred to emergency room for evaluation and management of metabolic alkalosis, hyperkalemia, and dehydration. There was no description of patient’s behavior. In interviews on 7/1/26 at 2:00 pm, DON Staff B and CEO Staff A acknowledged that the nursing skin assessments and documentation for Patient #1 were inconsistent and missing descriptions for bruises, which were noted on all the daily nursing assessments.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(A) Definitions. (i) A restraint is- (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or This Standard is not met as evidenced by: 43549 Based on observation record review and interview, the facility failed to uphold a patient’s right to be free of restraint. During a tour of the elderly “Red Unit” 9/8/25 at 1:00 pm three patients (C, G and H) were in the dayroom in fully reclined Geri chairs with staff nearby. Staff #3, Registered Nurse (RN) was asked why these patients were in the Geri chairs. She responded, “for fall protection.” She added that they could walk but were unsteady so were placed in reclined Geri chairs to prevent them from independently rising and falling. She said the patients cannot get out of the chairs independently, so they did not fall when in them. She was asked how long they had been in the chairs and stayed most of the morning, about three hours. She stated they will be getting up after lunch for “Walking group” where they are walking short distances, as able, for a few minutes. Staff RN #4 were asked the same, which elicited the same responses. Review of physician orders for patients (C, G and H) revealed none had orders for restraints. Staff RNs #3 and #4 were asked if the chairs reclined without patients being able to rise were restraints? Both stated they were unaware they were restraints so did not consider the need for an order for restraints or monitoring of them.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to thoroughly and effectively identify, address and resolve a complaint for 1 of 1 patient (Patient #8), as shown by evidence of incomplete investigation process. Findings included: Review of facility policy #RTS04 titled “PATIENT GRIEVANCE PROCEDURE’, last revised 2/123 showed an investigation to determine the validity of a grievance would be performed and appropriate state mandatory reporting guidelines would be followed. In addition, the patient advocate would issue a final written response to the grievance to include the steps taken to investigate the grievance. Record review at the time of survey of facility’s Grievance Log showed a report from Patient #8’s family member (the report did not specify which family member filed the complaint). The report simply stated the following: -3/17/23 notification of complaint concerning Patient #8. “Around 1:30 pm patient called his family and told them he hit his head against the wall and bleeding profoundly. Family became very worried, requested for a FaceTime.” -Date resolved: 3/17/24 (no letter sent). “..staff arranged the FaceTime call with the patient and family. But then patient told his family that he lied because he wants family to come pick him up. Complaint resolved at 3:30 pm same day”. Person doing investigation-Patient Advocate-Staff #G. Record review on 6/21/24 at 10:00 of Patient #8’s clinical chart showed the following: On 3/16/24, there were two incident reports generated for an event occurring at 9:51 pm. One was for an emergency medication given due to physical aggression and the other was for an injury sustained by the patient; ‘skin tear to head with bleeding, left leg abrasion’. Nursing progress notes date 3/17/24 showed “Wounds ....Scalp with abrasion type wounds to dermal layer at top of head ...”. In an interview on 6/21/24 at 12:00 pm, Staff #G stated that he received notice that the patient called his family and told them his head was bleeding. However, Staff #G stated he was not aware the patient sustained any injuries and was also unaware patient was restrained and given emergency medications at the same time. Staff #G also added that the investigation and response to family would have been different and more comprehensive had he known about all of the facts surrounding the restraint and concurrent injury. Staff #G also stated that there was no further investigation regarding the incident and believed it to be resolved at the time, not realizing the patient was actually reporting the truth to his family.”

“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: 23032 Based on record review and interview, the facility failed to ensure an effective abuse protection program related to the investigation of abuse allegations. The facility’s policy failed to require the availability of all portions of facility investigations of abuse for regulatory review and verification. Surveyor was unable to view video footage related to facility investigation of family allegations of abuse of Patient ID # 10, as it was not retained. Findings included: TX00496850 Record review of facility policy titled “Assessment and Reporting of Abuse, Neglect,” last revised date 5/30/2024 , section # 7. “If reporting is not mandatory...”: policy does not address retention of all documentation of facility investigation, including video footage for regulatory verification of a thorough investigation. Review of the clinical record of Patient ID # 10 showed she was an 83 year old female admitted to the facility on 3/15/2024 for increased agitation and physical aggression with a history of schizoaffectve disorder; bipolar type. Patient # 10 was discharged on 4/01/2024. Review of photos supplied to facility by family of Patient # 10 on 4/02/2024 showed: a large area of bruising on right shoulder blade extending over to right shoulder: color: green, yellow, and purple; and bruising to left shoulder. “Family expressed concern that patient was physically harmed on the weekend of 3/29 to 04/01/2024.” Record review of facility “Summary Report of Investigation,” dated 04/05/2024 showed the facility took the following actions (not all inclusive): -- reviewed medical record for nursing skin assessments -- interviews with staff : patient refused to lay down in bed in her room-“went to sleep on the hard chairs in day room.” - staff observed patient “on several occasions tossing, turning, and sliding back and forth on her back, on the hard chairs and all attempts to stop her failed...” Facility investigation showed details of camera review footage on 4/5/2024: “camera 17 & camera 19 (3/29/24 -1200 through 4/01/2024 at 0600 ) reviewed : pt sleeping on hard chairs in the group area. -staff are observed encouraging her to go to room- pt observed to be “wiggling” on the hard chairs, including appearing to rub her shoulder blades on the harder non-padded part of the chair. Pt observed laying on her back with her knees bent over the hard plastic arm of the chair. “ Surveyor was unable to view the video to validate the above information. During an interview with Staff A, Administrator, on 6/21/2024 at 10:30 AM, she stated the video was not kept, as the allegations were unsubstantiated. Facility documentation showed the allegations were unsubstantiated. The facility sent a letter to the family, dated 4/08/2024 that contained the details and findings of their investigation, per policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to ensure there was documentation of a restraint in 1 of 1 patient medical record (Patient #8), including no face-to-face 1 hour post restraint evaluation. Findings included: Review of facility policy#NSG-02 titled “Documentation”, Section: Nursing, last revised 1/1/23, showed that patient treatments and observations which reflect the care and progress a of the patient would be documented in the patient’s medical records. Also, that the RN would document pertinent and factual information, including assessments, interventions and outcomes related to the patient’s treatment. Review of another facility policy, #NSG-76 titled “SECLUSION AND RESTRAINT-TEXAS”, last revised 2/1/24 showed that as part of the facility’s procedure for restraints, the nurse would document contact with physician and also document that a one hour face-to-face post restraint evaluation form was completed. The form documented the date & time of restraint, patient behaviors, alternative interventions to prevent restraints and medical review of patient’s status post restraint. Record review at time of survey of Patient #8’s medical records showed the following: On 3/13/24 at 3:41 pm, the patient was restrained with the emergency behavioral medications Haldol 2.5 intramuscular injection (IM) and Benadryl 50 mg IM, due to aggression. Further record review of patient’s medical chart showed the patient was ordered and then given these emergency restraint drugs per the Medication Administration Record (MAR). However, the patient’s chart failed to show evidence of the required one-hour post restraint face-to-face evaluation being performed, any other assessments and evaluations, or patient monitoring. In addition, there was no other documentation in the patient’s records indicating a restraint had occurred: there was no incident report generated for the event, no nursing notes and no physician notes present in the chart addressing and explaining this restraint. In an interview on 6/20/24 at 1:30 pm while reviewing the patient’s records together, QD-Staff #H acknowledged the absence of the necessary documentation which should have been present in the chart.”

“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: 23032 Based on observation, interview, and record review, the facility failed to ensure a registered nurse supervised and evaluated the care of patients per professional nursing standards of practice [citing Patient IDs # 1, 10]. a.) Observation of Patient # 1 showed her sitting at bedside. An extremely strong odor of urine was noted upon entry to room. Adult brief found soaked and full of urine and feces. Facility policy does not require specific frequency of checking patients who are incontinent ; or require documentation that this nursing intervention is carried out. b) Review of medical record of Patient ID # 10 showed multiple inaccurate nursing skin assessments. Findings included : a) Nursing care of patients with incontinence: Review of facility policy titled “Activities of Daily Living (ADL),”dated 03/01/2023 showed : “...nursing personnel will clean and /or bathe incontinent pts. immediately upon voiding or soiling...nursing personnel will assess all incontinent (patients)...” The policy did not detail the specific frequency of assessing patients with incontinence ; or require documentation of this nursing intervention per professional nursing standards. ~~~~~~~~~~ Record review of Texas Administrative Code (TAC) Title 22; PART 11 Texas Board of Nursing ; CHAPTER 217 ; RULE §217.11 “Standards of Nursing Practice” showed: (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (B) Implement measures to promote a safe environment for clients and others; (D) Accurately and completely report and document: (ii) nursing care rendered; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible. ~~~~~~~~~ Observation during initial tour of the facility on 6/20/2024 at 9:25 AM showed Patient # 1 sitting at bedside of bed B. Surveyor was accompanied by Staff-C, mental health tech (MHT). Immediately upon entering the room, an extremely strong smell of urine was noted. Surveyor asked the MHT to request the Chief Nursing Officer (CNO), to come to the room. The CNO was in the hallway a couple of doors down. Both Staff- C, MHT and Staff -B, CNO acknowledged a strong odor of urine in the room. They were both asked how long ago this patient was checked and changed? Neither could answer this; CNO said he would find out. Patient # 1 was observed pulling at her pants, trying to stand and grasp her walker. Staff-B went to assist her to the bathroom, saying she was at risk for falls. The patient, MHT, & CNO went into the bathroom. Surveyor observed from the door as Patient # 1’s adult brief was removed. it was bulging and filled with urine and feces. Interviews after the observation between 9:30 and 9:50 AM were conducted: -Staff-C, MHT said: the process was that showers were started down at the end of all hall and patients were taken to toilet before shower. When asked how often patients with incontinence were were checked? he said “as frequently as we can.” He said there was no documentation. -Staff -D, MHT said “we should check for incontinence every 2 hours. We don’t document the checking; just if we change them.”’ -Staff- B, CNO said” incontinent patients are checked every 2 hours”; he later stated they were checked “periodically” and this was not documented. ~~~~~~~~~~~~~ b: Nursing skin assessments : Record review of facility policy titled “ Skin/Wound Care,” dated 10/01/2023, showed: - Nursing, in collaboration with the healthcare team , will assess and manage skin integrity for all patients upon admission and throughout their stay. - A skin assessment is completed by the registered nurse on all patients at admission, weekly, after a fall/injury, upon new skin findings and at discharge. During an interview with Staff-B, CNO, on 6/21/2024 at 10:20 AM he said: skin assessments were done every shift; full wound assessments were done on admission , weekly, on Saturdays, and at discharge. Review of Patents #10’s electronic medical record with the CNO showed : Daily shift RN assessment March 15- 24, 2024 (both day and night shifts): documentation showed “normal ; skin intact; no bruises” “3/24/2024 0200 AM: “weekly skin assessment : bruise noted to left forearm: picture taken.” Review of the photograph showed a large green, light purple, yellow bruise located in the inner aspect of the left forearm from the cubital fossa ( inner elbow crease) reaching almost to the wrist. RN assessments from March 25 to April 1, 2024 -after the picture taken -(both day and night shifts): showed “normal ; skin intact; no bruises.” CNO said the nursing skin assessments after March 24, 2024 were not accurate for Patient # 10 . Although she sometimes refused medications and assessments, this bruise to the left forearm was easily seen.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to protect the rights of Patient #1 by not recognizing and responding to a grievance and follow a process for prompt resolution for family members who complained about quality of care for 1 of 1 patients (Patient #A). Findings included: Record review of Patient #A’s medical chart showed a multidisciplinary note entry on 1/12/24 at 17:17 (5:17 pm) made by RN-Staff #10. The note showed that family members had called by phone and complained about bruises seen on the patient. They wanted to find out the reason why the bruises were present. RN-Staff #10 described the patient as having bruises to right arm, left shoulder, right and left thighs, and right lower abdomen. Also present in the chart were pictures of these bruises, taken on 1/12/24. These pictures were of the right and left shoulders, right and left inner thighs, lower abdomen, and right hand. Record review of nursing progress notes showed an entry made on 1/17/24 at 15:46. It stated that the patient’s family was very upset about the patient’s observed actions and were still worried about bruises they had observed on the patient. The notes explained that the family was concerned that the patient was being over medicated and sedated and were concerned about the reasons for the patient’s bruises. The patient was not able to verbalize what had happened with regards to the bruises, and the nursing notes further stated that the patient was unaware of the bruises. Further review of nursing notes and other interdisciplinary notes failed to show any follow up communication made with the family member who had made their complaints known to nursing staff about Patient #A. Record review of facility’s Grievance Report log failed to show any entries concerning Patient #A. In an interview on 1/31/24 at 9:00 am, CEO-Staff #1 and DON-Staff #2 acknowledged that the facility never followed through with a grievance process to resolve issues of complaints received from Patient #A’s family members.”

“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: 43549 Based on observation, and interview the facility failed to maintain patient shower stalls as shown by the presence of shower stalls with flaked paint, wall board and /or tile in rooms for 7 of 10 rooms observed (#s 103, 105, 106, 107 ,108, 110 and 111). During the initial tour at 10: 30 am with Staff #1 Chief Executive Officer (CEO) the room of a patient (E) who was in the dayroom and left a trail of water and wet footprints in the dayroom was entered (#106). The wall in the shower stall just below the showerhead was chipped and missing paint and portion of the baseboard in the bathroom was missing. Other observations during the tour were: Room 111 - The wall in the shower stall just below the showerhead was chipped and missing paint. Room 110 - The wall in the shower stall just below the showerhead was chipped and missing paint. Room 108 - The lower wall on the side of the shower stall just shower was gouged with an approximate 4x4x 0.25-inch portion missing chipped and missing. The wall below, abutting the baseboards were also chipped. The baseboards were pulling away from the wall. Room - 107 The entire length of wall in the shower stall just below the showerhead was bubbled up to approximately 6 inches above the shower enclosure and approximately a third of the way down the outer shower wall next to the shower enclosure. Paint was chipped and missing in various spots. There were previously patched areas visible that had bubbled and were eroding. Room 106 - The wall in the shower stall just below the showerhead was chipped and missing paint and portion of the baseboard was missing. Room 105 - The wall in the shower stall just below the showerhead was chipped and missing paint and portion of the baseboard was missing. Room 103 - The wall adjacent to the shower had baseboard missing. When interviewed 1/30/24 at 10:15 am Staff #1 confirmed the showers needed repair. Staff #1 stated the facility had identified which showers needed repair had a contract for repair. Staff #1 provided a form titled TE- KD Contractors INC, Wallcovering, Painting, Special Coatings. The business signature on the form was by Robert Moore dated 11/28/23. When interviewed 1/31/24 at 11:50 am via phone, Robert Moore from TE-KD Contractors stated the form he signed for Oceans Healthcare Pasadena on 11/28/13 was a “bid for general painting” and had nothing to do with patient bathrooms. He stated his company exclusively does painting and not construction or repairs. He added he was unaware of the facility bathroom issues.”

“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: 43549 Based on record review and interview the facility failed to ensure a registered nurse supervised and evaluated the nursing care, based on the patient’s condition for 1 of 1 patient (A) reviewed with injuries. Policies: Assessment Process Inpatient: Policy Number AS-01 Revised 02/01/2020 Policy: An Intake Screening and Assessment, Nursing Admission Assessment, Psychosocial Assessment, Recreation/Leisure Assessment, Psychiatric Evaluation, and a History & Physical Evaluation are preformed on all inpatient admissions in order to effectively identify patient symptomology and formulate an individualized treatment plan specific to the patient’s presenting problems. *The policy does not address nursing assessments after the initial admission assessment. Documentation: Policy Number NSG-02 Revised 01/01/2023 Policy: Inpatient nursing personnel document the patient’s progress every 12-hour shift, incorporating the elements of the nursing process and patient’s treatment goals and progress within the patient’s medical record. Daily: The Registered Nurse (RN) documents or reviews the LPN/LVN documentation on the Nursing Shift Assessment a minimum of once per shift. 1. All notes must be related to the patient’s problems on th treatment plan. Routine: RN and or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) documents all extraordinary occurrences and special needs (i.e., falls, etc.) in the multidisciplinary progress notes and documents any notifications or issues reported to the physician or non-physician provider (NPP), as applicable. The daily nurse note is only for daily assessment and expected occurrences. Discharge: The nurse completes a thorough discharge note in the multidisciplinary progress notes on discharge which includes the following information: *Time of discharge *Mode patient is discharged (via EMS, Patient family, Van transport etc.) *Patient’s physical/emotional status at time of discharge [skin assessment complete at time of discharge, patient stable at discharge, current behavior at discharge] Initial Nursing Assessment of patient #A by Registered Nurse (RN) #7 dated 1/8/24 documented Skin No rashes, No Bruises. Record Review of patient #A’s Admission History and Physical by Nurse Practitioner (NP) #14 dated 1/9/24 at 07:37 am documented Skin No rashes, No Bruises. RN Progress note of patient #A by RN #7 dated 1/12/24 from 7 am to 7 pm, 7 pm to 7 am documented skin as having bruising to right arm. Left shoulder, right thigh, and right abdominal fold. Pictures were taken and uploaded into the patient record. RN Progress note of patient #A by RN #15 dated 1/13/24 from 7 am to 7 pm documented Skin No Wounds, No Bruises, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present. RN Progress note of patient #A by RN #16 dated 1/13/24 from 7 pm to 7 am documented - Bruises. There was no documentation of location (s), number, descriptions or measurements of size, color, any edema present. RN Progress note of patient #14 by RN #19 dated 1/14/24 from 7 am to 7 pm documented Skin No Wounds, No Bruises, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present. Note indicated decreased skin turgor. RN Progress note of patient #A by RN #16 dated 1/14/24 from 7 pm to 7 am documented Skin No Wounds, No Bruises, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present. RN Progress note of patient #A by RN #16 dated 1/15/24 from 7 am to 7 pm documented No Skin Issues, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present. RN Progress note of patient #A by RN #17 dated 1/15/24 from 7 pm to 7 am documented Skin Normal, intact, no bruises, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present. RN Progress note of patient #A by RN #11 dated 1/16/24 from 7 am to 7 pm documented Skin Normal, Intact, no bruises, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present. RN Progress note of patient #A by RN #11 dated 1/17/24 from 7 am to 7 pm documented No Skin Issues, bruises on hands. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present. Patient discharged to hospital HCA Hospital 1/18/24 at approximately 16:00 for decreased alertness and altered mental status. Nursing note 1/11/24 by RN #10 read that Patient #A was very confused, and several times refused to allow a change of a brief soiled with a bowel movement (BM). That on 1/11/24 Patient #A had a soiled brief, was very combative and was throwing feces at staff and other patients as well as smearing it on walls and other surfaces. It indicated four staff were required to restrain her to get her changed and cleaned. Emergency medication was given. When interviewed 1/31/24 at 1:00 pm RN #18 stated the protocol was to leave skin assessment up to the provider. He stated that was the performance improvement. On 1/31/24 photos of patient #As bruises taken 1/12/31 were reviewed with RN #2 Director of Nursing. Photos displayed deep purple bruising to the right inner thigh. lower abdominal area, left upper arm and right upper shoulder. When interviewed 1/31/24 RN #2 at 1:20 pm RN #2 Director of Nursing was asked if the bruises should be described in the nurses notes. She could see that would be helpful.”