Perimeter Behavioral Hospital of Arlington

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 39057 Based on record review and interviews, facility contracted nurses failed to provide adequate supervision and evaluation for one of four patients (Patient #1) who fell on his arm during gym time and complained of pain. Patient #1 received an xray at that time. Nursing staff failed to evaluate the xray results that evidenced a fracture and failed to notify the provider and family. Findings include: Patient #1 was a 9 year old male admitted to the facility for increased mood instabilities to include aggressive behavior patterns and destructive outbursts. Patient’s psychiatric diagnosis were disruptive mood dysregulation disorder, generalized anxiety disorder, insomnia due to bipolar disorder. On 04/09/2026, Patient #1 sustained an injury after falling onto right hand during exercises in the gym. Review of order dated 04/10/2026 at 6:34 am, showed “TORB [telephone order read back] Xray right arm for past sport injury, Apply ice packs PRN to reduce swelling.” Review of radiology report with report date of 04/10/2026 at 12:15 pm showed “acute buckle type fracture across the proximal aspect of the proximal radial diaphysis. There is soft tissue swelling. No dislocation. Normal bony mineralization.” Electronically signed on 4/10/2026 9:12:15 PM CDT. During an interview on 07/13/2026 at 1:33 pm, Personnel #A reported a fracture was considered a change of condition and a positive radiology result was considered a critical lab value. Personnel #A stated nursing staff “failed to complete adequate chart check and failed to follow up on pending xray results.” During a telephone interview on 07/13/2026 at 2:07 pm, Personnel #E stated she did not see the results of the xray for Patient #1. Stated she thought the xray was still pending. Personnel #E reported nurses were able to retrieve xray results from the portal used by the x-ray company at any time. Personnel #E confirmed she signed off on the physician’s order on 04/10/2026 for the xray during her chart check process. During a telephone interview on 07/14/2026 at 12:02 pm, Personnel #G stated she was not informed by the hospital’s nursing staff that Patient #1 had a positive fracture result on his x-ray. Stated they learned about the fracture after the patient had been discharged. Personnel #G stated if they had been aware of the fracture result, they would have sent Patient #1 out for further evaluation. Review of “Critical Lab Values” policy revealed “It is the policy of Perimeter Behavioral Hospital to report all critical test results to the ordering physician within one hour of receiving the critical or panic results.” Procedure: “A. Laboratory, Radiology or EKG Personnel will call stat or critical lab values immediately upon receipt, or no less than four hours after the order of a STAT test to the house supervisor on duty ... E. The nurse will notify the ordering physician with the critical value as well as the reference range within one hour of receiving the critical or panic value.””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 33579 Based on Record Review, Interview and Observation the hospital failed to maintain its facilities and equipment to ensure it is mainatained at an acceptable level of safety and quality. Throughout the hospital the Air Conditioning units were not properly in service. Findings Include: During Interview with hospital Staff #5 it was reported that hospital A/C units are the toughest task the hospital is currently faced with. There are A/C’s that need parts or not operational. The hospital is currently waiting for quotes, waiting on warranty or scheduling repairs. We prefer the hospital to be maintained at 72 degrees. During Interview with the hospital Staff #3 it was reported, on patient unit Perseverance it was identified two patient rooms were 82 degrees and 81 degrees Fahrenheit . We would prefer rooms to be less than 78 degrees Fahrenheit. To mitigate this issue, we will move patients to another unit today. The unit will remain closed until we are able to evaluate the individual units in patient rooms and ensure they are working properly. In addition, we will not serve meals in the cafeteria until the temperature is below 75. The meals will be served on the units. Abacus environmental is on site identifying solutions for the cafeteria and atrium as well. During Observation during the hospital tour the hospital temperatures that were identified in jeopardy are as follows: - Seclusion Room Perseverance Unit 81 degrees - Perseverance Rooms 407 85 degrees 405 82 degrees - KITCHEN Cafeteria/Atrium 91 degrees Policy The hospital Policy on Patient Rights dated 07/17/2019, reflected, “The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations.” The hospital Policy on Administration/Personnel Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual’s needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives. The hospital Policy Physical Environment ‘Failure of Air Conditioning System 02/2025, “The Environment of Care Department will take the necessary steps to correct any failures of essential equipment or major utilities by following the procedure outlined in the Environment of Care Policy and Procedure manual. Perimeter Healthcare has a two-stage system that allows one unit to support all Air conditioning the event one unit fails.”

“Special Provisions for Psychiatric Hospitals CFR(s): Special Provisions Applying to Psychiatric Hospitals - Psychiatric hospitals must... This Condition is not met as evidenced by: 40989 Based on record review and interview, the hospital failed to ensure that changes in the admitting legal status in 1 (Patient #13) of 3 (Patient #4, #7, and #13) patient medical records reviewed were correct and had supporting legal documentation in the medical record to hold an involuntary patient for 38 days. The hospital failed to follow the Texas Administrative Code (TAC) 568.23(d)(5) and obtain an Order of Protective Custody (OPC) from the county judge at the end of 48 hours when holding a patient for admission with an Emergency Detention Warrant in accordance with the Texas Health and Safety Code 573.021(b) that states, “A person accepted for a preliminary examination may be detained in custody for not longer than 48 hours after the person was presented to the facility, unless a written order for protective custody is obtained. If the 48-hour period ends on a Saturday, Sunday, legal holiday, or before 4:00 PM on the first succeeding business day, the person may be detained until 4:00 PM on the first succeeding business day. If the 48-hour period ends at a different time, the person may be detained only until 4:00 PM on the day the 48-hour period ends. If extremely hazardous weather conditions exist or a disaster occurs, the presiding judge or magistrate may, by written order made each day, extend by an additional 24 hours the period during which the person may be detained. The written order must declare that an emergency exists because of the weather or the occurrence of a disaster”. Refer to Tag 1622”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 40989 Based on documentation review and interview, the hospital failed to ensure that all Psychoactive Medication Consents were signed by the patient, the legally authorized representative or had a court order signed by the County Judge to administer Psychoactive medications in 1 (Patient #13) of 3 (Patient #4, #7, and #13). Additionally, the hospital failed to follow the hospital policy titled “Informed Consent for Psychoactive Medications”. Findings: Patient #13 Patient #13 was a 35-year-old female who was admitted involuntarily to the hospital on 3/27/2025 at 11:19 AM with a diagnosis of Bipolar Disorder, Current Manic Severe with psychotic features, Cannabis Disorder with psychotic features, and General Anxiety Disorder. Patient #13 was transferred from the Gregg County jail by a peace officer and arrived at the hospital on 3/27/2025 at 11:17 AM. A review of the Emergency Detention Warrant (EDW) revealed that a Gregg County Judge signed the EDW on 3/26/2025. According to the Health and Safety Code Section 573.021(b), the EDW was valid until 3/29/2025 at 11:17 AM. There was no forced medication order from the county judge that allowed the hospital to administer psychoactive medications without the informed consent of Patient #13. Patient #13 had been held involuntarily for 36 days without an appropriate order. A review of the documents titled, “Consent for Treatment with Psychoactive Medications” signed and dated by Patient #13 was as follows: “ ...Seroquel (antipsychotic medication) 300 milligrams (mg) orally (PO) Q (every) night (HS). Patient consented to 200mg po qhs. Patient #13 signed the informed consent on 3/27/2025 at 2:15 PM. The witnessing nurse’s signature was illegible. Gabapentin (anticonvulsant medication used to treat symptoms of Bipolar Mania) 100 mg PO 3 times a day (TID). Patient #13 signed the informed consent on 3/27/2025 at 2:15 PM. The witnessing nurse signature was illegible. Lithium (Mood stabilizer) 600 mg PO twice a day (BID). Patient #13 signed the informed consent on 3/27/2025 at 2:15 PM. The witnessing nurse signature was illegible. Zyprexa (antipsychotic) 5 mg PO BID then increase to 15mg po qhs. Patient #13 signed the informed consent on 3/29/2025 at (time is illegible). The witnessing nurse signature was illegible. Patient #13 wrote a statement on the consent form. The handwritten statement was incoherent. Atarax (antihistamine medication used to treat anxiety) 50 mg PO BID as needed (PRN). Patient consented to 25 mg. Patient #13 signed the informed consent on 3/29/2025 at 10:30 AM. The witnessing nurse signature was illegible. Patient #13 wrote a statement on the consent form. The handwritten statement was incoherent. Gabapentin 300 mg po TID. Patient #13 signed the informed consent. There was no date or time when the patient signed the consent. The witnessing nurse signature, dated 4/04/2025 at 12:00 PM was illegible. Patient #13 wrote a statement on the consent form. The handwritten statement was incoherent. Gabapentin 600 mg PO BID-mood. Patient #13 signed the informed consent on 4/14/2025 at 1525 (3:25 PM). The witnessing nurse signature was illegible. Haldol (antipsychotic) 5mg PO BID x 3 days, then increase to 5mg PO TID. Patient #13 gave verbal consent on 4/15/2025 at 2250 (10:50 PM). Both nurses’ signatures on 4/15/2025 at 2250 (12:50 PM) were illegible. There was no documentation explaining why Patient #13 did not sign the consent and only gave verbal consent. Clozapine 25mg PO QHS, then increase 25mg PO BID on 4/29/2025. Patient #13 signed the informed consent on 4/26/2025 at 1940 (7:40 PM). The witnessing nurse signature was illegible. Clozapine 25mg PO BID then on 4/30/2025 PO Q AM and 50mg PO Q HS. Patient #13 signed the informed consent on 4/28/2025 at 1340 (1:40 PM). The witnessing nurse signature was illegible. Patient #13 wrote a statement on the consent form. The handwritten statement was incoherent. Clozapine 50mg PO BID on 5/02/2025 then increase to 100mg PO QHS and 50mg PO QAM on 5/04/2025. Patient #13 signed the informed consent on 4/30/2025 at 1820 (6:20 PM). The witnessing nurse signature was illegible...” A review of the physician’s emergency admission for mental health services documented 3/27/2025 at 11:48 AM revealed the patient presented with psychosis, mood swings, suicidal and homicidal ideations, audio and visual hallucinations, paranoia, delusional, disorganized, internally preoccupied, she was guarded and using marijuana. Patient #13 signed 3 psychoactive medication consents on this day. A review of Nurse Practitioner (NP) #13’s progress note dated 3/29/2025 revealed Patient #13 was responding to internal stimuli and believed her food was being poisoned, had paranoid delusions, and continued to have auditory and visual hallucinations. Patient #13’s judgment was impaired, and her insight was poor however Patient #13 signed 2 consents for treatment with psychoactive medications on this day. A review of Physician #11’s progress note dated 4/04/2025 revealed the patient was delusional and continued having auditory and visual hallucinations, she had poor judgment, and poor insight however Patient #13 signed psychoactive medication consents on this day. An interview was conducted with Physician #14 on 5/07/2025 after 9:00 AM. Physician #14 was asked if the patient had the capacity to understand the risks and benefits of treatment with psychoactive medications before the informed consent was signed. Physician #14 confirmed that Patient #13 did not have the capacity to understand the treatment. Physician #14 was asked if the physicians obtained informed consent for medications from the patient. An interview was conducted with Registered Nurse (RN) #10 on 5/06/2025 after 10:00 AM. RN #10 was asked if Patient #13 had the capacity to understand the risks and benefits of treatment with psychoactive medications. RN #10 stated, “She was not capable of understanding any treatment with medications and especially not when she first arrived. She probably should not have signed the consents”. RN Staff #10 confirmed that Patient #13 was receiving all medications that were prescribed. Physician #14 confirmed that the nursing staff were responsible for getting the patients to sign the informed consents for the medications. Physician #14 confirmed that they do discuss the medications with the patients as part of their daily visits, but Patient #13 did not have the capacity to understand. A review of the facility policy titled, “Informed Consent for Psychoactive Medications” was as follows: “POLICY: Psychoactive medications are administered with the patient’s informed consent and/or the informed consent of the patient’s legally authorized representative (LAR). Psychoactive medication may only be administered with the patient’s informed consent when the patient meets emergency criteria, has a legal guardian or legal authorized representative who consents for the administration of medication, and/or is under specific court order. Provisions applicable state states and regulations are followed to protect patient rights ...” An interview was conducted with Chief Nursing Officer (CNO) Staff #2 and Staff #3 on 5/06/2025 after 11:00 AM. Staff #2 was asked if Patient #13 had a court order for medications. Staff #2 confirmed that Patient #13 did not have a court order for psychoactive medications. CNO Staff #2 confirmed Patient #13 did not have an Order of Protective Custody with an order from the court to administer psychoactive medications. Staff #2 confirmed Patient #13 should not have been administered psychoactive medications without an order from the court due to her capacity to understand and give informed consent.”

“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: 36827 Based on review of records, observation, and interview, the facility failed to ensure patient monitoring was performed at the established time intervals ordered by medical staff to ensure patient safety on 1 (Adult Unit) of 2 units observed. On the morning of 05/07/25, unit observations were made with Staff #2 present for observations. The Unit had 18 patients. One patient was on a one staff member to one patient level of monitoring. That left 17 patients with two Mental Health Techs (MHT) to monitor them. Nine patients were assigned a level of monitoring of Q10 (every 10 minutes an MHT had to lay eyes on the patient and document the patient location and what they were doing). Eight patients were assigned a level of monitoring Q15 (every 15 minutes an MHT had to lay eyes on the patient and document the patient location and what they were doing). These time frames were assigned by the medical staff to ensure patient safety. On the Adult Unit, Staff #15, MHT was observed interacting with patients. Patient rooms were kept locked during the day. Staff #15 was observed unlocking a door for a patient to access his room. Two other patients were observed exiting their rooms on a different hallway. No other MHT was observed on the unit. Staff #15 was asked to show his observation sheets where he was documenting Q10 and Q15 minutes checks. He had two clipboards with observation sheets for all 17 patients. At 9:46 AM it was noted that the last checks for patients on Q10 minute checks had last been done at 9:30 AM. When asked why checks hadn’t been done Q10 as ordered by the medical staff, Staff #15 explained that the second MHT had to leave the floor to deliver a food tray. He had been doing patient laundry and opening doors for patients to use their restrooms, providing direct patient care. Because of this situation, it had made it logistically impossible for him to do both tasks, direct patient care and safety checks. Staff #2 confirmed the observations. Failure to perform safety checks as ordered could result in patients being unaccounted for with the potential for them to harm themselves or other patients on the unit and potentially creating an unsafe treatment environment for all patients.”

“PROTECTING PATIENT RECORDS CFR(s): 482.24(b)(3) The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with Federal or State laws, court orders, or subpoenas. This Standard is not met as evidenced by: 36827 Based on observation and interview, the facility failed to ensure confidential medical record information could not be accessed by unauthorized individuals in one of one treatment rooms observed. On the morning of 05/05/25 a tour of the hospital was conducted with Staff #1 and Staff #4. Staff #5 was present during the tour of the admission area. A room between the admission area and the hospital units was observed. This room was identified as a patient examination room used by both admission staff and the nursing staff for patient skin assessments. A form, commonly referred to as a face sheet, for Patient #6 was observed laying on the countertop. This form contained a picture of the patient, name, address, birthdate, date of admission, diagnosis, legal status of admission, and other confidential patient information. The form was from the patient admission date of 04/12/25 and could have been in the room for potentially 23 days allowing unauthorized staff and patients access to confidential patient information.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 36827 Based on observation of the environment, the facility failed to comply with providing a sanitary environment to avoid sources and transmission of infections and communicable diseases, creating an environment that could promote the spread of nosocomial (hospital acquired) infections and communicable diseases between patients and personnel in 3 out of 3 hospital areas toured. On the morning of 05/05/25, a tour of the Admissions area, Adult Unit, and Adolescent Girl’s Unit was made with Staff #1 and Staff #3. The following observations were made: Admissions Area The admissions waiting area had vinyl covered seating. The vinyl was observed to be cracked and peeling on 7 of the seats. Cracked and peeling vinyl allows for bacteria, germs, mold, and moisture to be trapped and prevents proper sanitation. The television in the admissions waiting area was secured behind plexiglass in a wooden frame. The wood was gouged, revealing unfinished wood. Porous wood allows for bacteria, germs, and moisture to be trapped and prevents proper sanitation. Adult Unit The medication room was observed. There were paper bags of donated items stored on the floor. A cardboard box with donated items was stored on the floor. Water bottles were stored on the floor. Items stored on the floor allow for dirt, dust, debris, and moisture to collect on items, promoting growth of bacteria, mold, and germs. The medication room lower cabinet was opened and observed to have a dried spill on the top shelf that appeared to have run out the bottom of the cabinet and was dried on the floor. In the back of the shelf with the dried spill was observed a personal drinking cup on it’s side, a Medline Aeromist Colors Nebulizer Compressor Kit in the box (used to provide breathing treatments to patients) and four decks of playing cards in their boxes. The cabinet to the right of this was opened. The shelves were observed to be heavily soiled with dirt/debris and had a box of gloves stored on that shelf. The door to the medication room had leftover pieces of clear tape where papers had been taped to the door. The tape and residue was observed to be dark with dirt stuck to the tape residue. Tape and tape residue allowed for bacteria, germs, and moisture to be trapped and prevents proper sanitation. The laundry area for patient laundry was observed. Patients were allowed to wear personal clothing and the clothing was laundered on site. The laundry equipment cleaning log for April was found to be incomplete for 17 of the 31 days without cleaning being logged. As of 05/05/2025, the log for May had not been started. The dryers were observed to have a heavy buildup of lint around the edges of the doors. The dryer on the right side had condensation built up on the door edge that was running down the door and to the floor. The vent screen was moist and rusted. Both washers had a build up of dirt and soap residue on the bottom and around the tub. The room for lab sample collections was observed. The sharps container for disposing of glass and sharp items (used needles) contaminated with biohazardous material such as blood and bodily fluids was observed to have the sealed lid removed. The sealed lid allows sharps to be placed in the container while protecting the staff from being punctured/injured, thereby preventing staff from contracting serious infections such as HIV, Hepatitis and other infections spread by contact with bodily fluids. Sharps containers have a line on them to mark when the container is full and should be replaced. The container was observed to be filled past the full-line and overflowing with contaminated sharps. This presented a serious risk for spread of infection to staff by accidental puncture with a contaminated sharp item. The biohazard disposal container for the lab room was observed to have a red topped glass specimen tube partially filled with blood. The container was lined with a red plastic biohazard disposal bag. Glass tubes, if broken during removal and disposal of the bag, could puncture the bag and skin of the person removing/disposing of the bag. This presented a serious risk for spread of infection to staff by accidental puncture with a contaminated sharp item. A urine specimen container with yellow liquid in it was observed on the counter of the patient examination room. The specimen container did not have a patient label so there was no way of knowing who the specimen belonged to or how long it had been sitting there. The specimen was unsecured in an area where psychiatric patients could handle it, presenting a risk of spread of infection from contact with bodily fluids. The sharps container in the patient exam room was filled past the full line, posing a potential risk of accidental skin puncture to staff when disposing of contaminated sharp items. This presented a risk for spread of infection to staff by accidental puncture with a contaminated sharp item. A styrofoam cup with water and what appeared to be a used band aid was observed to be sitting on the counter of the patient exam room. This was next to a box of crayons, a container of cleaning wipes, gallon container of shampoo/body wash and an unopened container of Vanilla Snack Pack pudding. Food products and crayons for children were at risk of contamination. Children’s Unit Upon entering the Children’s Unit, the floors were observed to be heavily soiled with dirt buildup. Hair and sand were observed on the floor. A deck of “Exploding Kittens the Rules” playing cards was observed to be laid out in an arrangement on the floor as if children had been playing with the cards. No children were present on the unit. A styrofoam cup was observed next to the cards. The cup had been partially broken apart with styrofoam pieces scattered on the floor. The floor presented an unsanitary location for children to be crawling around, playing, and eating/drinking.”

“Patient Legal Status CFR(s): The identification data must include the patient’s legal status. This Standard is not met as evidenced by: 40989 Based on record review and interview, the hospital failed to ensure that changes in the admitting legal status in 1 (Patient #13) of 3 (Patient #4, #7, and #13) patient medical records reviewed were correct and had supporting legal documentation in the medical record to hold an involuntary patient for 38 days. The hospital failed to follow the Texas Administrative Code (TAC) 568.23(d)(5) and obtain an Order of Protective Custody (OPC) from the county judge at the end of 48 hours when holding a patient for admission with an Emergency Detention Warrant in accordance with the Texas Health and Safety Code 573.021(b) that states, “A person accepted for a preliminary examination may be detained in custody for not longer than 48 hours after the person was presented to the facility, unless a written order for protective custody is obtained. If the 48-hour period ends on a Saturday, Sunday, legal holiday, or before 4:00 PM on the first succeeding business day, the person may be detained until 4:00 PM on the first succeeding business day. If the 48-hour period ends at a different time, the person may be detained only until 4:00 PM on the day the 48-hour period ends. If extremely hazardous weather conditions exist or a disaster occurs, the presiding judge or magistrate may, by written order made each day, extend by an additional 24 hours the period during which the person may be detained. The written order must declare that an emergency exists because of the weather or the occurrence of a disaster”. Findings: Patient #13 Patient #13 was a 35-year-old female who was admitted involuntarily to the hospital on 3/27/2025 at 11:19 AM with a diagnosis of Bipolar Disorder, Current Manic Severe with psychotic features, Cannabis Disorder with psychotic features, and General Anxiety Disorder. Patient #13 was transferred from the Gregg County jail by a peace officer and arrived at the hospital on 3/27/2025 at 11:17 AM. A review of the Emergency Detention Warrant (EDW) revealed that a Gregg County Judge signed the EDW on 3/26/2025. According to the Health and Safety Code Section 573.021(b), the EDW was valid until 3/29/2025 at 11:17 AM. A review of the document titled, “Physicians Preadmission Examination Orders and Preliminary Plan of Care” was as follows: “ ... Physician Evaluation Date and Time: 3/27/2025 11:48 AM. Admit Recommendations: Inpatient psychiatric unit, notify attending physician for admission. Present Legal Status: Involuntary. Physician Statement for Emergency Admission (with CME when applicable). May hold patient for involuntary admission while pending involuntary commitment filing with the court, as long as the hospital is compliant with the Texas Administrative Code. Admitting Legal Status: Involuntary ...” The hospital’s telehealth contracted service completed the pre-admission examination. A review of Patient #13’s medical record was conducted on 5/06/2025 with Registered Nurse (RN) #2 and Staff #9. The Initial Psychiatric Evaluation was completed by Physician #14 on 3/28/2025 at 11:23 AM. The mental status exam revealed that Patient #13 was anxious, had poor concentration, a disorganized thought process, delusional thought content with paranoid hallucinations, oriented to person only, short-term memory was not intact, poor insight, poor judgment, and poor reasoning. A review of the physician orders dated 3/28/2025-5/06/2025 did not show a written, verbal, or telephone order to hold Patient #13 for an Order of Protective Custody (OPC). An Order of Protective Custody is an order issued by a Probate Court after an Application for Court-Ordered Mental Health Services has been filed. Once the OPC is issued, an attorney is appointed to the case. The patient will go before the judge to determine if he/ she requires further inpatient psychiatric treatment and medications. The patient may waive their right to appear before the court after the attorney has counseled the patient. An interview was conducted with Staff #9 on 5/06/2025 after 11:00 AM. Staff #9 was asked if Patient #13 was a voluntary or involuntary patient. Staff #9 stated Patient #13 was admitted on an EDW and was still an involuntary patient. Staff #9 was asked to provide the OPC for Patient #13. Staff #9 stated, “We have been trying to get the judge in Gregg County to sign an OPC on the patient and we have not been able to get that done.” Staff #9 was asked to provide the completed OPC sent to the Gregg County judge and all communication showing the dates and times attempted to contact the judge. Staff #9 confirmed there were no documented notes or an OPC completed on this patient. Staff #9 confirmed the hospital did not have any documented proof that an OPC had been filed with the court once the EDW expired. An interview was conducted with Nurse Practitioner (NP) #13 on 5/06/2025 after 11:00 AM. NP #13 was asked if Patient #13 had the capacity to consent to voluntary treatment and psychoactive medication administration. NP #13 replied, “She is starting to respond to some treatment, but she does not have the capacity to understand the risks and benefits of the psychoactive medications, and she was not ready to consent for voluntary admission”. NP #13 confirmed there was no OPC on the medical record and there had been no order received by the attending physician for the hospital to obtain an OPC. An interview was conducted with Chief Executive Officer (CEO) #1, Chief Nursing Officer (CNO) #2 and the Director of Quality Staff #9 on 5/06/2025 after 11:30 AM. CEO Staff #1 confirmed Patient #13 was being held as an involuntary patient in the hospital without the legal documentation of an OPC for 38 days. CEO Staff #1 stopped all admissions to the hospital on 5/06/2025 at 12:00 PM for a comprehensive review of all involuntary patients’ medical records to ensure legal admission status was obtained and on the medical records of all patients affected. An interview was conducted with Physician #14 on 5/07/2025 after 9:00 AM. Physician #14 confirmed Patient #13’s admission status was changed from involuntary to voluntary on 5/06/2025, and Patient #13 signed the voluntary consent for treatment and admission on 5/06/2025.”

“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: 50856 This standard is not met as evidenced by: Based on record reviews, cameras recordings, and interviews, it was determined that the facility failed to provide an environment that ensured Patient B protection from harm. Findings include: Interviews: Interview with Staff #1 on 12/03/2024. Patient I and Patient B were playing basketball with peers in the gym on 11/15/2024 at 9:50am . Patient I bumped into Patient B. Patient B pushed Patient I. Patient I then punched Patient B in the face. Staff separated Patient I and Patient B. Interview with Staff #5 on 12/11/2024 at 4:27pm. Patient I and Patient B were playing basketball, and Patient B got angry because the other team was winning. They started cursing each other. Patient I jumped in front of Patient B and hit him. That’s when Staff #5 intervened and deescalated the issue. She stated she verbally told them to stop and separated them at the same time. Staff #5 stated, “When they were cursing I was walking toward where they were. The other staff was coming to come help me while they were cursing. Patient I slid right around me and punched Patient B. We could see the other kid, Patient I, went to try to fight another kid. He was on every 5-minute observations including gym time. That’s why I was close to Patient I because he was known to fight.” Record Review: Patient B’s medical record contained a nursing reassessment form that indicated Patient B had a chipped tooth as a result of a physical altercation. Camera recording: Facility provided camera recording of the gym on 11/15/2024 at 9:50am revealed that boys, including Patient B, were playing basketball. Staff #5 was standing less than three feet away from the boys. Patient B made a shot at the basket and missed. Patient I, who had previously been close to Patient B, had run about ten feet away. Patient B started walking quickly toward another peer just to side of the basket. Staff #5 followed and reached out and held Patient B’s shoulder keeping him from getting closer to the peer. At this same time, Patient I ran from his position about ten feet away. He ran through Staff #5 and Patient B and punched Patient B in the face as he did so. Afterward, Patient B is seen walking toward the middle of the court with his hand to his mouth. Record Review: Patient B’s medical record contained a nursing reassessment form that indicated Patient B had a chipped tooth as a result of a physical altercation. Policy review: According to the facility’s Patient and Family Handbook, patients have the basic right “to be treated with respect and dignity in a place that is clean and where you are protected from harm.” (Basic Rights page 3 of 4). The facility failed to ensure this right as Patient B suffered a chipped tooth as a result of a physical altercation with Patient I on 11/15/2024. Based on staff interviews, review of camera recordings, review of facility policies, and medical record review, the facilty failed to provide an environment that ensured patients were safe from harm in 1 out of 10 sampled patients (Patient B). This resulted in Patient B Being hit in the face and suffered a chipped tooth.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33326 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for a patient’s rights to a humane treatment environment that ensures protection from harm when, a.) The air conditioning unit in the facility’s Pediatric Unit seclusion rooms was not functioning, or placed out of use, placing any patients placed in the seclusion room at risk of heat cramps, heat exhaustion, and heat stroke. b.) The facility’s staff did not monitor and intervene when the pediatric boys were engaged in dangerous behaviors, placing the patients at risk of injury, and pain. c.) The facility failed to obtain Physician’s orders to place a patient (Patient #22) in seclusion, placing the patient at risk for an injury, or undue stress from an unauthorized confinement. Cross refers to: A144, A168”

“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: 33326 Based on observation, interview, and record review, the facility failed to protect a patient’s right to a humane treatment environment that ensures protection from harm, when, a.) The facility staff placed a patient (Patient #22) in the Boy’s Pediatric seclusion room when temperatures were 93F (degrees Fahrenheit) to 94F; the room’s air conditioning was not functioning, and the room had not been blocked from use. This failure places patients being placed in the seclusion room at risk of heat cramps, heat exhaustion, and heat stroke. b.) The facility staffs were not monitoring the patients to ensure their safety. This places patients at risk for injuries and possible elopement opportunities. Findings include: a.) Review of the facility provided policy, PATIENT RIGHTS AND RESPONSIBILITIES (revised 4/24/2024) reflected, “Perimeter Healthcare’s policy is to preserve the patient’s basic human rights during hospitalization, and that the patient’s behavior... Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation.” An observation made during a tour of the Pediatric Unit along with the Staff #1, Quality and Risk Director on 6/26/24 at 1:50 pm revealed, a closed locked door that led to the seclusion room suite; the suite had an anti-room with a chair and a bathroom connected to the area. There were three locked doors, each had a long window, used to observed into the room. The rooms had no furnishings, only a high frosted-out window. The back walls were shared with the building’s exterior wall, which was subjected to the outside temperatures. The seclusion rooms were unlocked, and the survey team entered the rooms, the rooms felt uncomfortably warm as did the anti-room. There was no signage showing the rooms were closed for repair. The isolation room temperature panel, behind the nurse’s station, did not display the room temperature. On 6/26/24 at 2:00 pm, Staff #3, Director of EOC (Environment of Care), was asked to take the temperature of the isolation room. Using the facility’s infrared thermometer, the room to the far left registered 95 F (degrees Fahrenheit), the middle room registered 96 F, and the room to the far right registered 96 F. During an interview on the afternoon of 6/26/24, on the pediatric unit, when asked if the nurse on duty was aware the air conditioning was not working in the seclusion room, Staff #7, RN stated, “No.” When asked for any patients that had been placed in the Isolation room, Staff #7 provided Patient #22, a 7-year-old-male’s, seclusion/Restraint record. Review of the Seclusion Packet dated 6/25/24 reflected, Patient #22 was placed into the Seclusion room three times: 12:05 pm to 12:25 pm (20 minutes), 12:30 pm to 12:40 pm (10 minutes), 3:20 pm to 3:45 pm (25 minutes). Review of, https://www.wunderground.com, reflected the temperatures for Arlington, TX on 6/25/24 from 1:00pm to 3:00 pm were 93F (degrees Fahrenheit) to 94F. During a telephone interview on 07/02/2024, when asked about placing Patient #22 in the seclusion room on 6/25/24, Staff #8, RN, the nurse that determined Patient #22’s placement into seclusion, stated, “We didn’t keep him in the room too long, because the room was too warm. I notified the house supervisor.” When asked if she looked at or used the temperature gauge, located behind the nurse station, used to indict the seclusion room’s temperature, before placing a patient in the room, Staff #8, RN stated, “No.” During an interview on the morning of 6/27/24, Staff #3, Director of EOC stated that he wanted to clarify what he told us yesterday. He stated yesterday that he had told us that the house supervisor reported the seclusion rooms being hot. He clarified that it was a therapist that told him their office was hot. Staff #3 confirmed the therapist office is close to the seclusions room where the AC was not working. The AC repairman was not here for the seclusion room; it was warm in the Therapist’s office, that is why I called them out. I wasn’t informed about the seclusion room. - When asked about the process for implementing a repair order and communication with the nursing department, Staff #3 stated in part, “Historically, really no process on how to submit an order. The staff will sometimes just tell me when something is needing repair. It’s been a - When asked how he prioritizes the repair requests? Staff #3 stated, “High, would be a Life Safety issue, something like a Fire extinguisher that got released. Medium, would be like a ligature issue, or a hole in a wall with sharp cutting edges exposed. Low, would be a regulatory issue.” Staff #3 confirmed the broken air conditioning had not be placed into the maintenance repair log. - When asked if the items needing to be repaired are reviewed by the Quality/Risk Director to determine the impact on the patient care? Staff #3 stated, “Not necessarily.” - When asked if there was a process for informing staff when equipment or a patient care area is not usable? Staff #3 stated a sign is placed to inform them. We also discuss it at the morning huddles. Staff #3 stated he was new at the facility and was not aware that the broken AC was connected to the seclusion rooms. - When asked what time was the broken AC reported on 6/25/24? Staff #3 was unable to provide a time of the notification, he did not record it in the maintenance repair logs. Review of the 6/26/24 huddle did not reflect a mention of the seclusion room being removed from service and patient use. b.) An observation on the morning of 6/27/24, on the facility’s pediatric unit along with Staff #1, Quality Director revealed, four adolescent boys running past Staff#2, MHT, (mental health technician); the staff member did not stop the children from the activity. The surveyor observed Staff #2, MHT, watching a children’s program on the television. The children continued to chase each other and nearly ran into the surveyor. The adolescent boys were chasing the leader of the boys around the room, until the leader jumped onto an approximately four-foot-high counter. The mental health technician did not turn to observe the children or intervene in this dangerous activity; he remained focused on the television. When this event was brought to the facility’s Quality Director’s attention, he interjected and instructed the staff to start a structured program. Review of the facility provided Observation Rounds Policy, revised 2/20/24 reflected, “1. POLICY: An accurate record of the whereabouts and behavior of all patients will be maintained during each shift. 2. PROCEDURE: A. An assigned staff member will have a list of all patients according to name and room number-, each shift. B. Every patient must be seen by a staff member at a minimum of every fifteen-minutes. C. A staff member will be assigned by the Nurse each shift to be responsible for the Patient Observation Record. D. The Nurse will be notified, and unit search done immediately for any patient not accounted for. E. If patient cannot be located, institute Elopement policy and procedure.6. Document patient location and behavior when the observation occurs on the patient observation form ... 7. While monitoring hallways and patient care areas ensure patients are: o Not entering rooms not assigned to them o Not in rooms or areas that are designated “off limits· areas lo patients o Not left in “treatment Areas” without direct staff supervision.” During an interview, on the morning of 6/27/24, on the boy’s pediatric unit, Staff #1, Quality Director was witness to the mental health technician’s not monitoring the patient activity and stated, “They must have just completed a program.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 33326 Based on interview, and record review, the facility failed to protect a patient’s right to a humane treatment environment that ensures protection from harm, when the facility failed to obtain a physician’s order for the restraint and seclusion of a patient on three separate occasions. (Patient #22). This failure places patients being placed in restraints or seclusion at risk of an injury, or undue stress from an unauthorized confinement. Findings include: Review of the facility provided policy EMERGENCY BEHAVIORAL INTERVENTIONS: USE OF RESTRAINT/SECLUSION (EFFECTIVE: 7/17/19) reflected, “It is the policy of Perimeter Healthcare to create an environment that protects the patient’s health and safety and preserves his or her dignity, rights and well-being. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others ... 11. Staff members must avoid causing undue physical discomfort and must not cause harm or pain to the individual when initiating or using restraint or seclusion .... PHYSICIAN ORDER 1. A physician order from a member of the Hospital’s medical staff is required for restraint or seclusion use as an emergency behavior management technique at Perimeter Healthcare. The physician’s order for restraint or seclusion must: A. Designate the specific intervention and procedures authorized, including any specific measures for ensuring the individual’s safety, health, and well-being; B. Specify the date, time of day, and maximum length of time the intervention and procedures may be used; C. Describe the specific behaviors which constituted the emergency which resulted in the need for restraint or seclusion; D. Describe the specific release behaviors that the individual must demonstrate before the restraint or seclusion will be discontinued; and E. Be signed, timed, and dated by the physician or the registered nurse who accepted the prescribing physician’s telephone order. 2. Because use of restraint and seclusion is limited to behavioral emergencies, and the physician may not be immediately available, a registered nurse (RN) is authorized by Perimeter Healthcare to assess the situation and initiate restraint or seclusion necessary for the safety of the patient and/or others. A. The order from the physician must be obtained no longer than one (1) hour after the initiation of seclusion or restraint. 3. If restraint or seclusion was ordered by telephone, the ordering physician must personally sign, time, and date the telephone order within 2 days of the time the order was originally issued. 4. If the physician who ordered the intervention is not the attending physician, the physician ordering the intervention must consult with the attending physician or physician designee as soon as possible. The physician who ordered the intervention must document the consultation in the individual’s medical record. 5. PRN or standing orders for seclusion or restraint are not acceptable or allowed. Review of Patient #22’s SECLUSION/ RESTRAINT & EMERGENY MEDICATION PACKET dated 6/25/24 reflected, “Complete Order (Completed by initiating nurse) Physical Restraint, Seclusion, & Emergency Medication must have an order from a physician.” Review of Patient #22’s seclusion/Restraint record dated 6/25/24 reflected the following placement times into the Seclusion room: 12:05 pm to 12:25 pm, 12:30 pm to 12:40 pm, and 3:20 pm to 3:45 pm. The three placement times were documented on one form. The medical record review did not indicate a physician’s order for the three placements into seclusion. During an interview, on the morning of 6/26/24, Staff #1, Quality and Risk Director, confirmed there was no physician’s order for patient #22’s three placements into seclusion and that each time the patient is placed in seclusion, the staff are required to complete a new packet including a new order for the seclusion placement.”

“A life safety code (LSC) survey was conducted onsite at the facility on 05/29/2024 and 05/30/2024. An entrance conference was held on 05/29/2024 with the following facility personnel: the Director of Quality and Risk Management, Environment of Care Director, and Vice President of Nursing, to discuss the purpose of the unannounced LSC onsite visit and the survey process was explained. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Psychiatric Hospitals, to determine the hospital’s compliance with 42 CFR §482.60(b), §482.41 Condition of participation: Physical environment. An LSC exit conference was conducted on 05/30/24 at the hospital. In attendance were the facility’s the Director of Quality and Risk Management, Environment of Care Director, and corporate management personnel (via phone). The preliminary findings of the survey and the next steps of the survey process were explained. An opportunity was provided for questions and discussion.”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to provide illumination of means of egress along the exit discharge path outside 1 of 2 exit doors (end of hallway exit) from the boy’s unit, in accordance with NFPA 101, 7.8.1.1, 7.8.1.2, and 7.8.1.4, as referenced by NFPA 101, 19.2.8. This failure could delay egress in the event of an emergency evacuation and potentially adversely affect the safety of the building’s occupants. Findings included: During observations and interviews on 05/30/24, in the boy’s unit of the facility, the exit door at the end of the hallway led to a fenced-in courtyard with a gate. There was a pathway and ramp from the exit door to the gate and parking lot. There were no lighting fixtures outside the exit door (minimum 2 sources required) nor anywhere along the ramp to provide illumination along the exit discharge path that was part of the required means of egress. The Environment of Care Director confirmed the observations when the surveyor discussed the finding.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to provide emergency lighting of the means of egress along the exit discharge path outside 1 of 2 exit doors (end of hallway exit) from the boy’s unit, in accordance with NFPA 101, 7.9, 7.9.1.1, and 7.9.1.2, as referenced by NFPA 101, 19.2.9.1. This failure could delay egress in the event of an emergency evacuation and potentially adversely affect the safety of the building’s occupants. Findings included: During observations and interviews on 05/30/24, in the boy’s unit of the facility, the exit door at the end of the hallway led to a fenced-in courtyard with a gate. There was a pathway and ramp from the exit door to the gate and parking lot. There were no lighting fixtures outside the exit door (minimum 2 sources required) nor anywhere along the ramp to illuminate the exit discharge path, that were powered by the Life Safety branch of the essential electrical system. The Environment of Care Director confirmed the observations when the surveyor discussed the finding.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to protect 1 of 1 mechanical room (located off the receiving hallway) with continuous smoke resisting partitions, in accordance with NFPA 101, 19.3.2.1 and 8.4.2. This failure could permit fire/smoke to spread to adjacent areas and potentially adversely affect the safety of the building’s occupants in the event of a fire. Findings included: During observations and interviews on 05/29/24, in the mechanical room containing boilers located off the receiving hallway, the left wall was not continuous to the floor. There was an approximate 6” tall section of the outer gypsum board layer missing along the base of the wall behind the boilers. The Director of Environment of Care confirmed the observations in the mechanical room when the surveyor discussed the findings.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 31958 Based on observation, interview, and record review, the facility failed to maintain 1 of 1 fire suppression hood system (in the kitchen), in accordance with NFPA 17A, 4.3.1.5 and 7.2, as referenced by NFPA 96, 10.2.6(4) and NFPA 101, 19.3.2.5.1 and 9.2.3, as follows: *blow off caps or covers were not provided on all the discharge nozzles, and *monthly quick check inspections were not conducted. These failures could affect the reliability of the fire suppression hood system and potentially adversely affect the safety of the building’s occupants in the event of a cooking related fire in the kitchen. Findings included: During observations, interviews, and record reviews on 05/30/24, the following were noted regarding the fire suppression hood system over the commercial cooking range in the kitchen: *All of the fire suppression discharge nozzles underneath the range hood did not have any covers or blow off caps installed to prevent grease or foreign materials from entering the piping. *The inspection tag at the manual pull actuator for range hood fire suppression system did not contain any dates or initials of a person performing quick check inspections. The facility’s Life Safety and maintenance records did not include any other documentation that quick check inspections (owner performed) for the kitchen’s fire suppression hood system. The Director of Environment of Care confirmed the observations of the kitchen hood’s fire suppression system when the surveyor discussed the findings.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to provide manual fire alarm pull stations at exit doors in 2 of 4 patient units (boy’s unit and girl’s unit), in accordance with NFPA 101, 19.3.4.2.1, 9.6.2, and 9.6.3. This failure could delay initiation of the fire alarm system in the event of a fire or emergency and potentially adversely affect the safety of the building’s occupants. Findings included: During observations and interviews on 05/30/24, there was no manual fire alarm pull station at either the exterior exit door at the end of the hallway or at the nurse station in the boy’s unit. Additionally, there was no manual fire alarm pull station at the either the exterior exit door at the end of the hallway or at the nurse station in the girl’s unit. The Director of Environment of Care confirmed the lack of manual fire pull stations when the surveyor discussed the findings.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to maintain 1 of 1 fire sprinkler system, in accordance with NFPA 25, 5.2.1.1.2(5). 5.2.1.1.4, 5.4.1.4, and 5.4.1.5, as follows: *Seven individual fire sprinkler heads were not maintained free of foreign material or dust, *Provide spare sprinkler heads for each type of sprinkler installed, and *Three individual sprinkler heads were missing their escutcheon plates. This failure could delay activation of fire sprinkler heads and potentially adversely affect the safety of the building’s occupants in the event of a fire or emergency. Findings included: During observations and interviews on 05/29/24 and 05/30/24, the following were noted regarding the building’s fire sprinkler system: *Five fire sprinkler heads surrounding cooking range hood in the kitchen had foreign material buildup and/or dust on their deflectors and response elements. *The sprinkler head near the pots/pans shelves in the kitchen, the sprinkler head in the kitchen pantry, and the sprinkler head in the transition hall outside the electrical room, were each missing an escutcheon plate. *The fire sprinkler head in the kitchen dishwashing area had discoloration and foreign material buildup. *The fire sprinkler head in the first laundry closet in the girl’s unit was loaded with dust. *There were no spare sprinkler heads provided for the upright extended coverage type sprinkler heads (installed in the gym) or the standard spray pendant type (ordinary temperature, quick response element) sprinkler heads. The Director of Environment of Care confirmed the observations of the sprinkler heads when the surveyor discussed the findings.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 31958 Based on observation, interview, and record, the facility failed to: *Conduct inspections at minimum 30 day intervals for 22 of 22 fire extinguishers located throughout the facility, in accordance with NFPA 10, 7.2.1.2 and 7.2.4.1. *Conspicuously identify fire extinguishers in cabinets located in all hallways throughout the facility, in accordance with NFPA 10, 6.1.3.1 and 6.1.3.10.2. This failure could delay extinguishment of a fire in an emergency and potentially adversely affect the safety of the building’s occupants. Findings included: During observations and interviews on 05/29/24 and 05/30/24, the following were noted: *The inspection tags on fire extinguishers located throughout the facility did not contain any initial and dates of a person performing inspections at minimum 30 day intervals. The facility’s Life Safety plan indicated 22 fire extinguishers located throughout the hospital. The facility’s maintenance records did not include any other documents that inspections (minimum 30 day intervals) of the fire extinguishers were conducted. *Fire extinguishers in hallways throughout the facility were located in recessed cabinets in the wall and were not identified with signage or markings that were identifiable when viewed from down the hallways. The Director of Environment of Care confirmed the observations of the fire extinguishers when the surveyor discussed the findings.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to ensure 2 of 5 smoke barrier walls (transition and boy’s unit) were constructed to a ½ hour fire resistance rating and resisted the passage of smoke, in accordance with NFPA 101, 19.3.7.3 and 8.5. This failure could compromise the integrity of the smoke barrier wall and permit smoke/fire to transfer from one smoke compartment to another in the event of a fire and potentially adversely affect the safety of the patients. Findings included: During observations and interviews on 05/30/24, the following were noted: *Above the smoke barrier doors to the transition hall, there was a 2-inch by 2-inch opening in the wall. *Above the hallway smoke barrier doors to boy’s unit, there was a 5-inch by 5-inch hole in the wall and a 2-inch by 3-inch cutout in the wall with an unsealed wire penetration through it. *Above the ceiling of the staff lounge smoke barrier wall in the boy’s unit, there was a 3-inch by 3-inch opening in the wall. The Director of Environment of Care confirmed the observations regarding the building’s smoke barrier walls when the surveyor discussed the findings.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 31958 Based on interview and record, the facility failed to conduct fire drills for 4 of 4 quarters each year for each work shift, in accordance with NFPA 101, 19.7.1.6. This failure could prevent prompt and effective staff response in the event of a fire or emergency and potentially adversely affect the safety of the building’s occupants. Findings included: During interviews and record reviews on 05/30/24, the Director of Quality and Risk Management said there were 2 different staff work shifts, 1st and 2nd shifts. The only fire drill documentation available was for a fire drill conducted in March 2024 for the 2nd shift. The Director of Quality and Risk Management said the previous fire drill documentation could not be located and there was no other documentation for previous conducted fire drills available.”

“Health Care Facilities Code - Other CFR(s): NFPA 101 Health Care Facilities Code - Other List in the REMARKS section any NFPA 99 requirements (excluding Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Health Care Facilities Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to: *Locate exhaust discharges at least 25 feet away from the air intake for 2 of 2 rooftop air handler units (serving the boy’s unit and girl’s unit), in accordance with ASHRAE 170, 6.3.1.1 as referenced by NFPA 99 9.3.3.1. *Locate the outside air intake height for 3 of 3 air handler units (serving the resilience unit, perseverance unit, and gymnasium) at least 6 feet above the ground, in accordance with ASHRAE 170, 6.3.1.1 as referenced by NFPA 99 9.3.3.1. *Provide positive air pressure in the medication room and clean linen room in 2 of 4 patient units (boy’s unit and girl’s unit), in accordance with ASHRAE 170, 7.1, Table 7-1 as referenced by NFPA 99 9.3.3.1. This failure could affect the indoor air quality and potentially adversely affect the health and safety of the building’s occupants. Findings included: During observations and interviews on 05/30/24, the following were noted: *On the roof, the rooftop air handler unit serving the boy’s unit had an exhaust fan located within approximately 15 feet from the unit’s air intake vents. *On the roof, the rooftop air handler unit serving the girl’s unit had an exhaust fan located within approximately 15 feet from the unit’s air intake vents. *The air handler unit serving the gymnasium had the bottom of its outside air intake vent located less than 1 foot off the ground. *The air handler unit serving the resilience patient unit had the bottom of its outside air intake vent located approximately 18-inches off the ground. *The air handler unit serving the perseverance patient unit had the bottom of its intake vent located approximately 18-inches off the ground. *In the medication room and clean linen room (located in the nurse station area) in the boy’s unit, there was no positive air supply functioning in each of the rooms. *In the medication room and clean linen room (located in the nurse station area) in the girl’s unit, there was no positive air supply functioning in each of the rooms. The Director of Environment of Care confirmed the observations of the air handler units and lack of airflow in the medication and clean linen rooms when the surveyor discussed the findings.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 31958 Based on observation, interview, and record, the facility failed to maintain 1 of 1 generator (providing emergency power for the hospital) as follows: *Appurtenant components were not inspected at least weekly, in accordance with NFPA 110, 8.3.4, 8.4, and 8.4.1. *Testing was not conducted under load at least monthly for at least 30 minutes, including operating the transfer switches, in accordance with NFPA 110, 8.4, 8.4.1, 8.4.2. This failure could affect the reliability of the emergency power system during a power outage and potentially adversely affect the safety of the building’s occupants. Findings included: During observations, interviews, and record reviews on 05/29/24 and 05/30/24, the following were noted: *A generator and automatic transfer switches were installed that provided emergency power to the hospital. *Weekly generator appurtenant components inspection logs available for review were dated 04/26/24, 05/06/24, 05/14/24, and 05/20/24. There was other no documentation for prior months that the generator’s appurtenant components were inspected weekly. *There was only one monthly generator testing log available dated 05/24/24 that indicated the generator was only run for 13 minutes including a 10-minute cool down time. There was other no documentation for prior months that the generator was tested under load for at least 30 minutes on a monthly basis. The Director of Environment of Care confirmed the observations regarding maintenance and testing of the generator when the surveyor discussed the findings, and said that no other weekly or monthly generator logs were available.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 28141 Based on observation, interview, and record review, the hospital failed to ensure that patient rights were protected and promoted for at least 11 of 11 patients (Patients #8, #11, #43, #45, #46, #47, #48, #4, #51, #53, #56). 1. The hospital failed to ensure the right to a specific time frame for review of patient grievances and provision of a response for two of two patients (Patients #8 and #11) whose filed grievances included allegations of a sexual assault and patient injury. Altogether, 188 complaints logged in 2024 did not evidence a response outcome letter to the complainants. Refer to A 122 2. The hospital failed to ensure the right to receive care in a safe setting for nine of nine patients including a) all five patients on the hospital’s preadolescent girls’ unit (Patients #43, #45, #46, #47, #48) who had been admitted with command hallucinations to kill or hurt self, poor impulse control, physician-assessed poorly controlled response to behavior modifying treatment, and/or severe mental deterioration that required close observation for self-harm and suicide attempts. The patients had access to non-food items including in-wall insulation material, plasterboard and paint peelings, potentially ingestible during a self-injury attempt, for at least 24 hours during the survey, b) four adolescent patients (Patients #4, #51, #53, #56), admitted for depression, self-harm, with increased suicidality and plans and/or previous attempts of suicide by shooting, stabbing, or hanging. During their inpatient hospitalization, the patients had access to plastic spoons, a piece of glass, a screw and screwdriver, and a nail from a broken wall and used these objects in self-harming attempts. In addition, one patient retained a charger cord for future self-harm in the hospital, and another patient drank the Nitric Acid Ammonium Salt solution of the hospital-provided ice-pack and required emergency medical evaluation and poison control guidance. c) no fire drills and/or fire inspections had been conducted. Refer to A 144. 3) The hospital initiated a restraint on one of one patient (Patient #4) without obtaining a physician order. At the time of survey, the adolescent patient refused to be discharged to the designated care giver, got upset, grabbed two plastic spoons out of a trash can and cut herself, jumped over the barrier that separated the nurses’ station from the milieu, banging her head on the wall in self-harm attempts. Unable to calm down with continued physical and verbal aggression, Patient #4 was staff restrained and escorted off the unit where she sat on the floor in a small area between two locked exit doors for more than an hour awaiting arrival of police and emergency services for continued self-harming behavior. Refer to A 168 4) No verified emergency behavior management competency was provided for one of one staff member who physically picked up Patient #11, age 6, from a bed; the patient struggled and resisted, and the staff member dropped him to the floor. Refer to A 208.”

“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: 37325 Based on record review and interview the hospital failed to have an organized nursing service that provides 24-hour nursing care. 1. Nursing staff failed to ensure that 2 of 3 patients (Patient #2 and Patient #4) received a nursing assessment for their medical conditions that included Patient #2’s fractured hand on admission and Patient #4’s deeply lacerated arm wound after the patient found a piece of glass in her treatment environment and used it to cut herself. In addition, 1 of 3 patients (Patient #70) did not receive a nursing admission assessment after being admitted to the facility. Cross refer to A 395 2. Nursing staff failed to ensure that the care plan for 12 of 12 patients (Patients #51, #52, #53, #56, #54, #4, #57, #61, #65, #2, #55, #83) were kept current to reflect the patients’ self-harm attempts, critical medical conditions, and/or emergency behavior interventions.. Cross refer to A 396”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 47061 Based on record review and interview, the facility failed to ensure the provision of a response to a grievance, in that 2 of 2 patients (Patient #8 and Patient #11) did not receive a response to a grievance within the specific time frames. Findings Include: Patient #8’s mother filed a grievance on 03/08/2024 for allegations of sexual assault and never received a response outcome letter from the facility. Patient #11’s mother filed a grievance on 05/06/204 for allegations of patient injury and never received a response outcome letter from the facility. Record review of the Complaint and Grievance log on 05/20/2024 at 2:00 PM reflected that 188 complaints had been logged from 02/01/2024-5/20/2024. The outcome response for all 188 entries did not evidence a response outcome letter was sent to any of the complaints listed. During an interview with Personnel #8 in a 1st floor office on 05/15/2024 at 9:00 AM stated the following, “I have worked here since 2/19/24. I remember the incident with [Patient #11] ...She let me know about everything that had happened ...She asked me if I knew anything about her son being dropped by an employee and I told her no, but I did tell her that I would address it. I always write up my complaints and then move them up for resolution. I submitted it to [Personnel #10], and he told me that it was already on their radar. The mom also called me for an update which I usually do within 48 hours of receiving a complaint. I updated mom by phone of the status of where we were in the investigation ...she did request that there be additional investigation regarding this incident because she felt the facility failed her son. I forwarded that email on to [Personnel #10] per the mom’s request. Once I forward an email to quality/risk then I do not follow up with families. [Personnel #10] will follow up with the families regarding the outcome of an investigation ... I have not sent out a single grievance outcome letter since I started last February ...I’m not sure what our policy says about how the patient advocate handles family follow up with outcomes and letters ...I know the policy states that if I can handle the issue within 7 days then it is considered a complaint, anything after 7 days then it becomes a grievance ... I remember [Patient #8]. Her mom called me after [Patient #8] was discharged. She stated that [Patient #8] told her that she was tongue kissed on the mouth and butt by her roommate. I sent an email to [Personnel #10] regarding the incident. I went and spoke with her roommate/perpetrator because she was still admitted when I received the call. The roommate admitted to liking [Patient #8]. She told me that she showed [Patient #8] how much she liked her by kissing her. I asked her where she kissed her, and she said mouth. I asked her if she kissed [Patient #8] anywhere else and she said no ...I went back and called mom and let her know that I was sending the complaint up. I did tell her that the roommate admitted to kissing [Patient #8] on the mouth. I apologized because we didn’t know the incident had occurred or we would have acted ...An outcome letter was never sent to the family as far as I know.” During an interview with Personnel #10 in a 1st floor office on 05/15/2024 at 11:00 AM stated the following, “[Personnel #8] is responsible for closing the loop with patients and their families ...It is in her job description and listed on her competency checklist ... Grievance letters are supposed to be sent out by [Personnel #8] ...” The facility policy on “Grievance Procedure” (Reference # 1004) effective 07/17/2019 reflected the following, “ ...Definitions ...A ‘patient grievance’ is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient’s representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoP) ...If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purpose of these requirements. A complaint is considered resolve when the patient or other person is satisfied with the actions taken on their behalf ....A written complaint is always considered a grievance ...All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered grievances for the purposes of these requirements ...Procedure ...Provide a response to a patient and/or other person making a grievance complaint within seven days of receiving the grievance ...Take action to resolve all grievances promptly and fairly; and document all grievances, including final disposition, and keep the documentation in a central file ...Resolution Activities ...When resolution has been determined, the person reporting the grievance should be notified of the result. Notification of the resolution must be documented and contain the following information: Steps taken on behalf of the patient to investigate the grievance; date investigation was completed; the results of the grievance process; and name of hospital contact person ...Grievance Coordinator/Committee ...The Patient Advocate shall operate as the grievance review and response coordinator. A committee may be called including the Chief Executive Officer, Chief Nursing Officer, Chief Operating Officer, Human Resources personnel, and/or other departmental leaders as warranted ...The Grievance Coordinator and/or Committee will review and manage grievances as delegated by the Hospital governing Board, in writing. A process will be established to provide periodic reports to the Performance Improvement Committee and Medical Executive Committee. The process is to include the aggregation, trending and analysis of data related to grievances, actions taken, and resolutions attempted.””

“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: 28141 Based on observation, interview and record review, the facility failed to ensure the rights of nine of nine patients (Patients #43, #45, #46, #47, #48, #4, #51, #53, and #56) to receive care in a safe setting. 1. Five out of five female preadolescent patients on suicide and self-harm precautions (Patients #43, #45, #46, #47, and #48) had access to non-food items potentially ingestible during a self-injurious attempt in form of in-wall insulation material and broken plasterboard for at least 24 hours at the time of survey. Patients #43, #45, #46, #47, and #48 had been admitted on suicide and self-harm precautionary staff observation based on the patients’ intent to hurt or kill themselves and/or listening to voices telling them to kill themselves. In addition, Patient #43 had access to paint peeling off the wall in her patient room for potential non-food ingestion and self-harm. Patients #43, #45, #46, #47, and #48 were inpatient hospitalized at the time of survey and included a) Patient #43, age 8, who had been admitted with physician ordered close staff observation to be treated in a therapeutic environment without access to hazardous triggers due to her impulsivity, b) Patient #45, age 11, who was physician noted to be a danger to herself with poor response to treatment and unpredictable thought processes, c) Patient #46, age 11, admitted for suicidal ideation and on self-harm precautions, d) Patient # 47, age 11, who had been physician assessed to be a “ticking time bomb” with self-injurious behavior and heard “evil” voices that told her to kill herself, e) Patient #48, age 10, who had auditory hallucinations of demons telling her to kill herself and was noted with poor response to behavior modification. 2. Four of four adolescent patients (Patients #4, #51, #53, #56) had access to objects and used them in self-harm attempts during their hospital stay. a) Patient #4 had been inpatient hospital admitted for depression and self-harm after taking 12 pills of a veterinary medication without notifying anyone. Within 24 hours of admission, the patient found a piece of glass in the pause room, used it to make deep cuts onto her left arm that required an emergent transfer to acute care. Two days prior to her discharge, Patient #4 found a charger cord potentially usable in a self-harm attempt. Later, the patient refused to discharge, got upset, and found two plastic spoons in her treatment area that she used to self-harm. b) Patient #51 was admitted with increased suicidality and plans to stab or shoot himself, cutting his throat, or hanging. One week into his hospital stay, Patient #51 found a screw in the courtyard and used it to scratch himself; two day later he ingested the Nitric Acid Ammonium Salt containing liquid of a hospital provided icepack and required emergency medical evaluation and poison control guidance. c) Patient #53 had been admitted after a suicide attempt of hanging, self-cutting, and self-harming behavior. Within a week of hospitalization, the patient had access to a broken plastic spoon and used it in a self-harm attempt. d) Patient #56 had been inpatient hospitalized for self-cutting behavior. One day after his admission, Patient #56 found a screwdriver on the floor and used it to cut on himself. Two days later, Patient #56 found a nail from a broken wall and, again, used that object to cut on his left arm. 3. Two large screwdrivers were found on a vacant unit during the survey. 4. No records or current history of Fire Drills and Fire Inspection were available at the time of survey. Findings included: 1. Observation on the preadolescent girls’ unit on 05/14/2024 at around 11:01 PM reflected the dayroom had a hole in the wall. The hole was the size of approximately 10 cm by 15 cm, in reachable height for patients, and gave access to plasterboard wall edges and inside-wall insulation material. Personnel #45 accompanied the surveyors and acknowledge the finding at that time. The hole was observed again on 05/15/2024 at 01:30 PM. Personnel #73 stated at that time that the hole was due to a “patient incident last month.” A patient room, Room #215, was observed with paint peeling off the wall leaving an area of three feet by three feet of exposed wall in reach and accessible to two patients observed in bed at that time. Record review of the patient census sheet provided to the surveyor by Personnel #45 on 05/14/2024 at around 11:01 PM reflected there were five patients on the preadolescent unit at that time and included: a) Patient #43’s Face Sheet reflected an admission dated of 05/02/2024 at 04:53 PM. The patient was a transfer from a children’s hospital. Admission Evaluation dated 05/02/2024 at 05:07 PM reflected Patient #43 had command hallucinations and a psychiatric history of hurting self by head banging and “sucking on arms causing bruises.” The patient was reported with “lying, impulsive, and hyperactive behaviors ...[that] have increased ...” and “ ...psychosis ...auditory, visual hallucinations ...” Physician’s MOT (Memorandum of Transfer) Orders dated 05/02/2024 at 04:52 PM reflected Patient #43 was on every 10-minute staff observation in a “therapeutic environment removed from current triggers or stressors ...no access to ...open hazards, guarded from impulsive, accidental harm ...” Patient #43’s Comprehensive Psychiatric Evaluation dated 05/03/2024 at 11:05 AM reflected Patient #43 identified a problem to be addressed that the patient was a danger to herself and suffered from psychosis; the initial treatment plan included to “decrease suicidal ideation.” Physician Daily Progress Notes dated 05/14/2024 and 05/15/2024 noted Patient #43’s insight and judgment were “fair” with “poor impulse control.” Close observation form dated 05/15/2024 reflected Patient #43 was on suicide and self-harm precautions. The patient was noted to be in Room 215 A. b) Patient #45’s Face Sheet reflected the 05/07/2024 at 12:26 AM admission date and time. Patient #45’s Comprehensive Psychiatric Evaluations dated 05/07/2024 at 08:40 AM reflected the patient had “poor coping skills” and was a “danger to self and others.” She had been aggressive at home, was irritable, anxious, labile, and was physician-noted for “poor decision making.” Patient #45’s Physician Daily Progress Notes dated 05/08/2024, 05/09/2024, 05/10/2024, 05/11/2024, 05/12/2024, 05/13/2024, 05/14/2024, and 05/15/2024 reflected the patient’s response to behavior treatment was “poorly controlled” and her judgment was “fair.” The physician noted on 05/12/2024 at 09:20 AM that Patient #45 had an “unpredictable mind.” Patient #45’s Patient Observation Form dated 05/15/2024 reflected that the patient was on suicide and self-harm precautionary staff observation levels. c) Patient #46’s Nursing Shift Progress and Assessment dated 05/14/2024 at 07:50 PM reflected the patient’s 05/10/2024 admission date. The patient had been admitted for suicidal ideation. The nurse noted that “safety checks were in progress ...” and the patient was on suicide precautionary status. Patient #46’s “Observation Form Q10” document dated 05/15/2024 reflected the patient was on suicide and self-harm precautions and staff observation. d) Patient #47’s Face Sheet reflected the patient was admitted on 05/13/2024 at 04:39 PM. Patient #47’s Assessment and Referral Evaluation dated 05/13/2024 reflected the patient’s statement that “the doctor told us to come here ...because of suicide.” The patient’s behavior was noted to be highly irritable, a “ticking time bomb” with disruptive behaviors and emotional outbursts. Staff assessed Patient #47 to have “pressured” and “rambling” speech, display “bizarre” behavior, was in “anxious” and “manic” mood and her thought process was “disorganized.” Her judgement and insight were “poor.” She had engaged in self-injurious behavior within a month prior to her admission and was assessed to be of “high suicide risk” level. Patient #47’s Preadmission Evaluation and Medical Clearance screening dated 05/13/2024 at 05:23 PM reflected a suicide attempt “last week” together with self-injury behavior, auditory hallucinations, feelings of hopelessness and helplessness, sad and tearful mood, pressured speech, excessive worries and nervousness. The physician concluded “severe mental/physical deterioration or incompetence” based on ‘currently available information.” Comprehensive Psychiatric Evaluation dated 05/14/2024 at 09:49 AM reflected Patient #47’s suicidal plans to stab self; she heard “voices in her head” that sounded “like God ...an evil god that tells her to kill herself ...” Patient #47’s Physician Orders dated 05/14/2024 at 07:26 AM reflected the patient was on suicide and self-harm precautionary status. Patient #47’s Physician Daily Progress Notes dated 05/15/2024 at 07:31 AM reflected a “poorly controlled behavioral response to treatment.” The patient’s judgement and insight were “fair.” Patient #47’s Patient Observation Form dated 05/15/2024 reflected that the patient was on suicide and self-harm precautionary staff observation levels. e) Patient #48’s Face Sheet reflected her admission date of 05/10/2024 at 09:46.PM The Preadmission Evaluation dated 05/10/2024 at 11:55 PM reflected Patient #48 had suicidal ideation and “demons telling her to kill her.” The patient reported thoughts of suicide and self-injurious behavior and was assessed to be of high risk of suicide, delusional, with auditory and visual hallucinations. Physician-ordered precautionary observation levels included self-harm, suicide, and aggression. Physician Orders dated 05/11/2024, 05/12/2024, 05/13/2024, 05/14/2024, and 05/15/2024 reflected the patient was on physician ordered suicide and self-harm precautionary staff observation levels. Physician Daily Progress Notes dated 05/14/2024 at 09:45 AM and 05/15/2024 at 07:20 AM reflected Patient #48 had a “poorly controlled behavioral response” to treatment, and her “judgement and insight ...[were] fair.” The above findings were discussed with Personnel #10 on 05/15/2024 at 04:20 PM who acknowledged the findings at that time. Research at the University of Michigan (2021) identified at least 55 “chemicals of concern” found in walls (Research Identifies 55 Dangerous Chemicals in Building Materials | News | University of Michigan School of Public Health | Environmental Health Sciences | Building | Construction | Health | (umich.edu) 2. During the time of hospitalization, adolescent patients #4, #51, #53, #56 had access to objects that included a piece of glass, a nail, a screw and screwdriver, and broken plastic spoons. The patients used them in self-harm attempts during their hospital stay and required medical and nursing attention and/or emergency care. a) Patient #4’s Face Sheet reflected her admission date of 05/03/24 at 04:00 PM. The Assessment and Referral Evaluation dated 05/03/24 at 104:18 PM reflected Patient #4 had multiple cuts on her left arm and both upper and lower legs. The week prior to admission the patient had taken 12 Vistaril tablets that belonged to the dog and did not tell anyone. The Multidisciplinary Progress Notes dated 05/04/24 with no time noted reflected ...”she was scared about how deep she cut her arm. Pt (patient) shared she hadn’t meant to cut that deep, that she’d found a piece of glass in Pause Place and just wanted to feel it ...” Patient #4 was transferred to an acute care hospital for stitches to the left forearm. The Multidisciplinary Progress Notes dated 05/15/24 at 04:00 PM reflected...”Pt (patient) was discussing thoughts of SH & SI (self-harm/suicidal ideation) w/ (with) therapist. She handed Th (therapist) a charging cord and said ‘Here, take this. I found it and was keeping it to SH...” The Multidisciplinary Progress Notes dated 05/17/27 at 08:30 PM reflected...”patient still continued to refuse to be discharged...patient grabbed the trash bag and threw it on the floor, grabbed one of the spoons, cut herself. Staff members intervened and removed the broken spoon from her hand, continue to make attempts to take another spoon to cut herself...” The above findings were discussed with Personnel #10 on 05/21/24 at 04:49 PM who acknowledged the findings at that time. b) Record review of Patient #51’s Face Sheet reflected the 16-year old patient was hospital admitted on 02/08/2024 at 02:03 PM. He was discharged on 02/18/2024 at 11:00 AM. Patient #51’s Discharge Summary dated 03/01/2024 at 04:21 PM noted the patient’s admission and discharge diagnoses that included Disruptive Mood Dysregulation Disorder. The patient was admitted with increased suicidality and plans to stab or shoot himself, cutting his throat, or hanging. He was aggressive, impulsive, with low frustration tolerance, and “hearing his father’s voice and others telling him to hurt himself and others ...” Patient #51’s Progress Notes dated 02/15/2024 at 01:50 PM reflected the patient had found a screw in the courtyard and scratched his right and left arm. Notes timed at 01:55 PM reflected the patient was assessed with “multiple cuts on both forearms” and “patient stated he was frustrated ...” Patient #51’s Multidisciplinary Treatment Plan Update dated 02/15/2024 reflected the patient “still reports thoughts of SI [Suicide Ideation] ...” Patient #51’s Physician Orders dated 02/17/2024 at 05:00 PM reflected to transfer the patient to the ED for immediate evaluation due to “Patient swallowed instant cold pack medline and call poison control ...” The manufacturer’s Material Safety Sheet for Icepacks listed Nitric Acid Ammonium Salt as one of the main ingredients and noted in case of ingestion “do not induce vomiting ...call physician immediately ...” (SDS0186_Standard Instant Cold Packs.pdf (medline.com) c) Patient #53’s Face Sheet reflected the 14-year-old patient’s admission date of 03/24/2024 at 11:36 AM as a transfer from an acute care hospital. Admitting diagnoses included Disruptive Mood Dysregulation Disorder. Patient #53’s Progress Notes dated 04/01/2024 at 02:00 PM reflected nursing documentation that the patient used a broken plastic half spoon in a self-harm attempt and cut a wound to her left forearm. Patient #53 Discharge Summary dated 04/18/2024 at 07:01 AM reflected the patient had been admitted after a suicide attempt of hanging, self-cutting and self-harming behavior. Patient #53’s Initial Treatment Plan dated 03/24/2024 at 10:44 AM reflected the patient’s treatment goals to decrease suicidal, homicidal and disruptive behavior. d) Patient #56’s Discharge Summary dated 04/18/2024 at 07:01 AM reflected the 15-year-old patient was admitted on 03/27/2024 for self-cutting behavior. Prior to his admission, the patient was struggling with poor impulse control, low frustration tolerance, and the thoughts of hanging himself. He was noted with “disregard for his safety of self ...finding a screwdriver on the floor on 03/29/2024 and making cuts to self ...” Patient #56’s Shift Progress Notes dated 03/30/2024 at 07:15 PM reflected the patient “was found with wall nail from broken wall ...making many small cuts to his LUE [left upper extremity] ....” Patient #56’s Shift Progress Notes dated 03/30/2024 at 08:10 PM reflected the patient stating that self-harm was “a way for me to take care of things.” Personnel #10 acknowledged the above findings during an interview on 5/21/24 at 04:25 PM. 3. Observational rounds were conducted on patient care units 05/14/2024 at around 11:00 AM and Staff #68 and the surveyor entered the hospital vacant unit. On this Unit two large screw drivers were found and unattended. During an interview on 05/14/2024 at 11:00AM Hospital Staff #68 stated in response to obtaining the screw drivers, “I do not know who is responsible for the screw drivers or do I know how long they have been there.” During Interview with Hospital staff #10 on 05/14/2024 at 11:45AM. “I am not certain who is responsible for any equipment, in reference to the screw drivers on the vacant unit. I believe the EOC department is responsible. We are looking to open the vacant unit as soon as possible.” During Interview with Hospital Staff #58 at 12:15PM on 05/14/2024. “I was told that two screws were found on the unit, not 2 screw drivers. I hold my staff accountable for hospital equipment. This may belong to outside vendor.” 4. During Interview with hospital Staff #58 on 5/14/2024 at 12:20PM, “Can you provide the fire inspection reports and fire drills?” Staff #58 reported that he has been employed for that past 44 days at the hospital and has not observed a Fire Drill or has there been a fire inspection. Staff #58 indicated that he has placed calls to the fire department but has not received a return call to schedule fire inspection. Staff #58 reported there are no previous records that hospital has provided him with or that he is aware the hospital has.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 37325 The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law Based on observation, record review and interview the facility failed to obtain a physician’s order for the restraint of 1 of 1 (Patient #4) patients. Findings included: Patient #4’s The Multidisciplinary Progress Notes dated 05/27/24 at 08:30 PM reflected ...”writer received a call from office stated patient’s mom at the front desk for discharge. Patient was informed about going home, patient bluntly refused stated ‘I am not going home to those (unreadable), I am not going anywhere’ ... Patient continued behavior, refused for discharge, pack her stuff to go home ...Patient began to be physical aggressive, irritable, anxious, and agitated towards staff members. Patient jumped the nursing station by climbing and ran to the other side of the unit, banged at the exit door in an attempt to elope, banged on the wall severely to self-harm. Patient continues to bang on the wall, glass to the nursing station and seclusion door. Patient unable to calm down, continues to be physically and verbally aggressive... 09:00 PM Patient was restrained and escorted out of the unit for discharge. At the exit door, patient was banging the wall, attempted to yank off the time clock, banged at the glass to the exit door. Patient refused to calm down, refused to go to the car of her family member...Patient continues to be physically aggressive towards hospital property by banging on the glass and wall at the exit door and still refused to go...09:11 PM House Supervisor called 911 for intervention and safety in cooperation with family member...10:00 PM Police officers arrived, before the police arrived, patient continues to pick on her left hands, picking on the old wounds to make it more open. Patient refused to be redirected. Police officers called for EMS (Emergency Medical Service).” After Patient #4 was sitting on the floor between the exit doors for 1 hour and 45 minutes EMS arrived and took patient to an acute care hospital. During an interview on 05/21/24 at 03:57 PM Personnel #74 acknowledged the findings. Personnel #74 acknowledged the patient was secluded without an physician’s order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 47061 Based on record review and interview, the facility failed to document in the staffing personnel records that restraint/seclusion training and skill’s competencies were successfully completed for 1 of 15 employees (Personnel #21). Finding include: On 05/15/2024, a review of the personnel file for Personnel #21 did not evidence that a skill’s competency checklist had been performed since her date of hire of 03/18/2024. During an interview with Personnel #9 in a 1st floor office on 05/15/2024 at 9:30 AM stated the following, “[Personnel #21] did participate in Handle with Care...[Emergency Patient Behavior Management] training during orientation. During an interview with Personnel #10 in a 1st floor office on 05/15/2024 at 11:00 AM he confirmed the above findings that Personnel #21’s skill’s competency checklist had not been completed. During a phone interview with Personnel #21 on 05/23/2024 at 3:02 PM Personnel #21 stated they did not recall completing a competency for emergency patient behavior management. Personnel #21 recalled an incident where they attempted to manage Patient #11’s emergency behavior; the patient struggled and fought Personnel #21. Patient #11 was dropped to the floor. The facility policy on “Abuse, Neglect, Exploitation, Unethical, or Unprofessional Conduct” (Reference #1030) effective 07/17/2029 reflected the following, “ ...Perimeter Healthcare shall monitor the qualifications and competencies of providers of services and/or staff. Perimeter Healthcare shall not allow unqualified persons or entities to provide services ...””

“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: 37325 A registered nurse must supervise and evaluate the nursing care for each patient. Based on record review and interview a registered nurse failed to evaluate the care of each patient 1. 2 of 3 (Patient #2 and Patient #4) patients did not receive a nursing assessment for medical conditions. The nurses failed to assess the fractured right hand of Patient #2 and to reassess the patient after administration of pain medications. The nurses failed to assess the lacerations on Patient #3’s arm after they cut themselves with glass found her treatment environment. 2. 1 of 1 (Patient #70) did not receive a nursing admission assessment after being admitted to the facility on 04/23/24 Findings included: Patient #2 was admitted to the facility on 04/19/24 for Major Depressive Disorder and a fractured right metacarpal. The Nursing Shift Progress and Assessment note dated 04/19/24 at 08:30 PM reflected Patient #2 was given Tylenol 325 mg for pain to the arm. The progress note did not reflect an assessment of the hand, did not identify which hand was painful, and the progress note did not reflect a follow-up assessment for the effectiveness of the pain medication. The Nursing Shift Progress and Assessment note dated 04/22/24 reflected Patient #2 complained of hand pain. There was no documentation of which hand was painful and there was no documentation of an assessment of the hand. The Nursing Shift Progress and Assessment note dated 04/22/24 at 08:59 PM reflected Patient #2 was given Tylenol 325mg for right hand pain. There was no documentation of an assessment of the right hand and no documentation of a reassessment to verify if the pain medication was effective. Patient #4 was admitted to the facility on 05/03/24 for Major Depressive Disorder. The Multidisciplinary Progress Notes dated 05/04/24 with no time noted reflected ...”she was scared about how deep she cut her arm. Pt (patient) shared she hadn’t meant to cut that deep, that she’d found a piece of glass in Pause Place [the quite room] and just wanted to feel it ...” There was no documentation of the laceration nor an assessment of the laceration in the nursing documentation. The Shift Progress Note dated 05/08/24 at 01:42 PM reflected the patient complained of a cough and sore throat. There was not a documented assessment of the patient’s throat or lungs. The Shift Progress Note dated 05/15/24 at 08:15 PM reflected ...”PRN (as needed) inhaler used for SOB (short of breath) via MAR (medication administration record)” ... There was no documentation of an assessment of the patient’s lungs on the chart. There was no documentation regarding the effectiveness of the inhaler. Patient #70 was admitted to the facility on 04/23/24 for bipolar disorder and discharged from the facility on 05/18/24. The Nursing Admission Assessment in the medical record is blank. During an interview on 05/15/24 at 12:15 PM Personnel #10 verified the missing documentation for Patient #2 and Patient #4. During an interview on 05/21/24 at 02:49 PM Personnel #10 verified the missing documentation for Patient #70. The policy titled Assessment and Reassessment of Patients effective 07/17/19 reflected ...”3. The RN (Registered Nurse) Nursing Admission Assessment is completed within eight hours of admission ...Reassessments of patients are to be completed when there is a significant change in patient condition ...””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 28141 Based on record review and interview, the hospital failed to ensure that nursing staff kept a current care plan for each patient that reflected the patient’s goals and the nursing care to be provided to meet the patients’ needs for 12 of 12 patients who a) had a self-injurious incident during their hospitalization including acts of self-harm using objects such as a nail, screw and screwdriver, broken plastic spoons, and a piece of glass the patients found in their treatment environment (Patients #51, #52, #53, #56, #54, #4), b) suffered medical conditions including Diabetes Mellitus to address severe blood sugar swings, and acute musculoskeletal and integumentary injuries requiring nursing interventions (Patient #57, #61, #65, #2), and/or c) had an emergency behavior management episode (Patient #55, #83). The hospital failed to reflect the events in the patients’ care plans as part of the care teams’ evaluation of interventions and care provision. Finding included a) Record review of Patient #51’s Face Sheet reflected the 16-year old patient was hospital admitted on 02/08/2024 at 1403. He was discharged on 02/18/2024 at 1100. Patient #51’s Progress Notes dated 02/15/2024 at 1350 reflected the patient had found a screw in the courtyard and scratched his right and left arm. Notes timed at 1355 reflected the patient was assessed with “multiple cuts on both forearms” and “patient stated he was frustrated ...” Patient #51’s Physician Orders dated 02/17/2024 at 1700 reflected to transfer the patient to the ED for immediate evaluation due to “Patient swallowed instant cold pack medline and “call poison control ...” Patient #51’s Multidisciplinary Treatment Plan Update dated 02/15/2024 reflected the patient “still reports thoughts of SI [Suicide Ideation] ....” Revised interventions included for clinical staff to “monitor pt for manipulation when he is not getting attention or his way ...” The document was not signed by nursing or medical staff. There was no evidenced documentation of treatment plan updated after the 02/17/2024 incident. Patient #51’s Discharge Summary dated 03/01/2024 at 1621 noted the patient’s admission and discharge diagnoses that included Disruptive Mood Dysregulation Disorder. The patient was admitted with increased suicidality and plans to stab or shoot himself, cutting his throat, or hanging. He was aggressive, impulsive, with low frustration tolerance, and “hearing his father’s voice and others telling him to hurt himself and others.” During the course of treatment, the patient was noted to have continued auditory and visual hallucinations, “difficulties with impulsivity ...feeling hopeless ...helpless ...continued levels of depression ....still feeling suicidal ....” The patient emergently required a medical evaluation on 02/17/2024 after having “ ...ingested liquid from the torn icepack ...” The manufacturer’s Material Safety Sheet for Icepacks listed Nitric Acid Ammonium Salt as one of the main ingredients and noted in case of ingestion “do not induce vomiting ...call physician immediately ...” (SDS0186_Standard Instant Cold Packs.pdf (medline.com) Patient #52’s Face Sheet reflected the 14-year-old patient was admitted on 03/01/2024 at 0923. Admitting diagnoses included Bipolar Disorder, Generalized Anxiety Disorder, and Attention-Deficit-Hyperactivity Disorder. Patient #52’s Comprehensive Psychiatric Evaluation dated 03/02/2024 at 2158 reflected was admitted in patient hospital care due to a recent suicide attempt by hanging; the patient had wrapped a curtain around her neck until she passed out. The admitting diagnoses included Bipolar Disorder, current episode, depressed, severe, with psychosis. Patient #52’s Shift Progress Notes dated 03/05/2024 at 2142 reflected the patient “had earlier been involved in physical altercation with another patient ...is intrusive, calling peers names ...threatening to beat them up ...” Physician Order dated 03/05/2024 at 2225 noted a telephone order to transfer Patient #52 to a different unit for “safety.” Patient #52’s Multidisciplinary Progress Notes dated 03/06/2024 at 2057 reflected the patient got into a physical altercation with a peer, was choked and left with red marks on her neck. Physician Orders dated 03/06/2024 at 2137 reflected an order to place Patient #52 on one-to-one staff observation “for safety.” Patient #52’s Shift Progress Notes dated 03/07/2024 at 0825 reflected the patient was “ ...self-harming via using the fingernail to scratch self ...[at 1400] patient continued cutting self to blood on the forehead ...” Clinical Services Group dated 03/07/2024 from 1100 to 1200 reflected Patient #52 was observed “self-harming in a corner despite being on 1:1 [staff observation].” Clinical Services Group dated 03/07/2024 for the 1400 Psych Education Group that the patient “was trying to self-harm at the end of the hallway and mostly refused to talk with Therapist and refused to practice any coping skills to calm down ...” Shift Progress Notes dated 03/08/2024 at 1350 reflected Patient #52 was “bleeding from the cuts on the hands ...cleaned up by RN ...” Multidisciplinary Progress Notes dated 03/09/2024 at 1700 reflected that Patient #52 was in the seclusion room after she had thrown a heating pad at the nurse and attempted to kick staff. The patient “started pulling the wall using the pieces to try to hurt self ...slapped the MHT [Mental Health Technician] ...” Patient #52’s Discharge Summary dated 03/25/2024 at 1928 reflected the patient had suffered from auditory and visual hallucinations, felt hopeless and helpless, with high risk behavior such as sending naked pictures to a man. During the course of treatment, the patient was noted to be unpredictable, with peer conflict, prone to mood swings and self-scratching and self-abusing behaviors and was placed on one-on-one “to address the self-harm ....significant loss of control of behaviors on 03/09/2024 ...discharged on 03/11/2024 with recommendations to follow up with RTC [Residential Treatment Center].” During an interview on 05/21/2024 at 1547, Personnel #10 acknowledged that the treatment plan did not reflect the events. Patient #53’s Face Sheet reflected the 14-year-old patient’s admission date of 03/24/2024 at 1136 as a transfer from an acute care hospital. Admitting diagnoses included Disruptive Mood Dysregulation Disorder. Initial Treatment Plan dated 03/24/2024 at 1044 reflected the patient’s treatment goals to decrease suicidal, homicidal and disruptive behavior. Progress Notes dated 04/01/2024 at 1400 reflected nursing documentation that the patient used a broken plastic half spoon in a self-harm attempt and cut a wound to her left forearm. Physician Orders dated 04/01/2024, untimed, reflected the patient was restricted to finger foods and was not to use utensils. Multidisciplinary Treatment Plan Updated dated 04/01/2024 at 1000 reflected that Patient #53 “has been actively engaging and has not reported SI [suicidal ideation] since 03/28 but has reported SH [self-harm] and HI [homicidal ideation] thoughts.” The document was signed by nursing staff on 04/03/2024 at 1300. There was no evidence of a self-harming incident on 04/01/2024 with a broken plastic spoon or the patient’s restriction to finger foods as of 04/01/2024. Patient #53 Discharge Summary dated 04/18/2024 at 0701 reflected the patient had been admitted after a suicide attempt of hanging, self-cutting and self-harming behavior. Admitting and discharge diagnoses included Major Depressive Disorder, recurrent, severe, without psychotic features. During her course of treatment, Patient #53 was assessed with remaining suicidal ideation, impulsivity and labile mood. She was discharged on 04/05/2024 to a lesser level of care in residential treatment. Personnel #10 reviewed the chart and acknowledged the above findings during an interview on 5/21/24 at or around 1630. Patient #56’s Discharge Summary dated 04/18/2024 at 0701 reflected the 15-year-old patient was admitted on 03/27/2024 for self-cutting behavior. He discharged on 04/03/2024. Prior to his admission, the patient was struggling with poor impulse control, low frustration tolerance, and the thoughts of hanging himself. He was noted with “disregard for his safety of self.” Admission and discharge diagnoses included Major Depressive Disorder, recurrent, severe, without psychotic features, and Fetal Alcohol Syndrome as medical diagnosis. During the treatment course, Patient #56 was limited to finger foods “for safety” on 03/28/2024; wound care was ordered “to address cuts on arms and stomach ...finding a screwdriver on the floor on 03/29/2024 and making cuts to self ...” Physician Orders dated 03/30/2024 at 1150 reflected the patient was ordered on every 5-minute staff observation rounds for self-harm. Physician Orders dated 03/30/2024 at 2200, on 03/31/2024 at 1210, on 04/01/2024 at 0840, and 04/02/2014 at 0830 reflected the patient remained on every 10-minute observational rounds. Patient #56’s Shift Progress Notes dated 03/30/2024 at 1000 reflected the patient got into a “physical confrontation with peers ...” Patient #56’s Shift Progress Notes dated 03/30/2024 at 1915 reflected the patient “was found with wall nail from broken wall ...making many small cuts to his LUE [left upper extremity] ....” Patient #56’s Shift Progress Notes dated 03/30/2024 at 2010 reflected the patient stating that self-harm was “a way for me to take care of things.” Patient #56’s Master Treatment Plan dated 03/27/2024 reflected the patient’s level of monitoring to be every 15 minutes. There was no evidenced the care plan was updated to reflect the increased, 10-minute observational staff rounds for 03/30/2024 through the patient’s discharge day. There was no evidence that the patient’s two self-harming incidents, using a screwdriver on 03/29/2024 and a nail on 03/30/2024, were addressed in the treatment plan. Personnel #10 acknowledged the above findings during an interview on 5/21/24 at 1625 and stated that “the care plan had not been updated.” Patient # 54’s Face Sheet reflected the 13-year-old patient’s 04/17/2024 admission and 05/02/2024 discharge dates. Patient #54’s Admission Evaluation dated 04/17/2024 at 1557 reflected the patient had made a suicide attempt by overdosing on “5 to 6 Depakote 175mg [milligram]” and stating that the attempt “was a good idea.” Patient #54’s Physician Memorandum of Transfer Orders dated 04/17/2024 at 2229 included orders to place the patient on self-harm precautions. Patient #54’s Comprehensive Psychiatric Evaluation dated 04/18/2024 at 0800 noted the patient’s chief complaint that she “tried to OD [overdose].” The physician noted a conversation with a patient’s family member who stated Patient #54 was “cheeking meds [keeping medication in her mouth instead of swallowing them].” Physician Orders dated 04/19/2024 at 0046 required nursing staff to “check mouth for cheeking after meds.” Orders dated 04/20/2024 at 0900, 04/21/2024 at 1218, 04/22/2024 at 0820, and 04/23/2024 at 0830 noted that nursing staff should “check for cheeking (meds). The Initial Treatment Plan dated 04/17/2024, not timed, and the Master Treatment Plan dated 04/19/2024 reflected the patient’s suicide attempt. There was no evidence of family contributing information to the plan, and neither plan reflected the patient’s previous “cheeking meds” self-harming behavior. The Multidisciplinary Treatment Plan Updated dated 04/24/2024 at 0915 noted that the patient had continuous suicidal and self-harming ideation with a plan; the revised interventions did not reflect the order for nursing to check the patient’s mouth for retained medication. Personnel #10 reviewed the patient chart during a personal interview on 5/21/24 at 1546 and acknowledged the findings. Patient #4 was admitted to the facility on 05/03/24 according to the patient Face Sheet. The Multidisciplinary Progress Notes dated 05/04/24, not time noted, reflected ...”she was scared about how deep she cut her arm. Pt (patient) shared she hadn’t meant to cut that deep, that she’d found a piece of glass in Pause Place and just wanted to feel it ...” Patient #4 was transferred to an acute care facility on 05/04/24 for stitches to the left forearm. The Master Treatment Plan did not reflect Patient #4’s left forearm laceration as a medical problem. During an interview on 5/15/24 at 1215 Personnel #10 verified the findings for Patient #4. b) Patient #57’s Face Sheet reflected the 15-year-old female patient’s admission date of 02/12/2024, timed at 2255. The patient was discharged on 02/16/2024 at 1320. Discharge Summary dated 02/27/2024 at 1551 reflected Patient #57 was admitted after refusing her diabetic medications in order to try to kill herself and a previous suicide attempt by grabbing a knife. The patient felt hopeless, helpless, and felt her life was worthless. She was admitted for inpatient crisis stabilization. Admitting diagnoses included Disruptive Mood Dysregulation Disorder, Generalized Anxiety Disorder, Diabetes Mellitus, Hypothyroidism, Gastroesophageal Reflux Disease. Patient #57’s History and Physical Physician Examination dated 02/13/2024 at 1250 reflected the patient was noncompliant with her insulin administration and had a history of Diabetic Keto Acidosis. Multidisciplinary Progress Notes dated 02/15/2024 at 0310 reflected Patient #57’s blood sugar was 56 mg/dL, rose to 227 mg/dL at 0430, and 316 mg/dL at 0733. Physician Orders dated 02/16/2024 at 1305 reflected Patient #57’s emergency transfer to an acute care hospital “for hyperglycemia.” The Master Treatment Plan dated 02/13/2024 reflected “Diabetes” as a medical diagnosis; the problem list with medical problem resolution was left blank, and there was no evidence of a nurse review as the space for nursing to sign as part of the interdisciplinary treatment team was left blank. Patient #61’s Face Sheet reflected the 11-year-old patient was admitted on 02/15/2024 at 0400 and discharged on 02/23/2024 at 1118. History and Physical Examination dated 02/15/2024 at 1000 reflected the patient had been admitted due to suicidal ideation and threats. She had made a suicide attempt by cutting herself on a rock. She had pain in her right hand due to an injury due to physical altercation. Physician Orders dated 02/15/2024 at 1105 directed nursing staff to apply ice to the patient’s right hand every six hours for 15 minutes for a right-hand injury. Patient #61’s Initial Treatment Plan dated 02/15/2024 reflected as medical problems “none.” The Master Treatment Plan dated 02/15/2024 did not reflect any medical diagnoses and did not reflect the right-hand injury. There was no evidence of a Multidisciplinary Treatment Plan for Patient #61’s right hand injury and ice application. The patient’s Multidisciplinary Treatment Plan Updated dated 02/22/2024 at 0900 did not reflect a right-hand injury; the plan was not reviewed by nursing staff as evidenced by a blank signature line. Patient #65’s Face Sheet reflected the 12-year-old patient had been admitted on 05/01/2024 at 1255. She was discharged on 05/13/2024 at 1630. Patient #65’s Physician History and Physical Examination dated 05/02/2024 at 0800 noted the patient was admitted due to worsening anger, self-harm and suicide ideation. The patient used a razor to cut her arms. The physician noted left forearm laceration and recommended to “monitor wounds.” Patient #65’s Master Treatment Plan dated 05/01/2024 did not reflect the left forearm laceration as a medical problem. There was no evidence of a Multidisciplinary Treatment Plan Problem Sheet in Patient #65’s medical record that addressed the potential for infection or worsening of wound on the patient’s left forearm. Personnel #10 reviewed the medical records of Patients #57, #61, and #65 during a personal interview time on 05/21/2024 at or around 1630 and acknowledged the findings. Patient #2 was admitted to the facility on 04/19/24 with a fractured right 4th metacarpal. The right had was splinted and the patient was wearing a sling to the right arm. The Initial Treatment Plan dated 04/19/24 and the Master Treatment Plan dated 04/25/24 do not reflect the patient had a fractured right hand. During an interview on 5/15/24 at 1215 Personnel #10 verified the findings for Patient #2. c) Patient #55’s Face Sheet reflected the 12-year-old was admitted on 04/15/2024 at 1732. Admitting diagnoses included Major Depressive Disorder, recurrent. The patient was discharged on 04/29/2024 at 1251. Patient #55’s Physician Comprehensive Psychiatric Evaluation dated 04/16/2024 at 0950 noted the patient had been admitted for aggression and voicing suicidal ideation at school and jumping off a balcony in a suicide attempt. He suffered from auditory and visual hallucinations and saw “shadow people ...out to get him.” Psychiatric diagnoses included Major Depressive Disorder, Recurrent, Severe, with Psychotic Features. Emergency Safety Intervention Justification dated 04/22/2024 at 1026, 04/22/2024 at 1127, and 04/24/2024 at 1735 reflected physician ordered restraints for Patient #55 for imminent harm to self. Interventions to assist Patient #55 in achieving his goal of no risk to himself, dated 04/15/2024 at 2330, were left blank. Interventions to assist Patient #55 in achieving his goal of no risk to himself dated 04/22/2024 at 1103, 04/22/2024 at 1228, and 04/24/2024 at 1819 reflected the intervention that nursing “shall insure availability and correct dosage and administration of medication as prescribed by the attending medical provider...as needed.” There was no evidence of specific nursing interventions to decrease the patient’s self-harming behavior. Multidisciplinary Treatment Plan Update dated 04/23/2024 at 0900 did not reflect nursing staff’ reviewed Patient #55’s care plan. Multidisciplinary Progress Notes dated 04/25/2024 at 1510 reflected an attempt by Patient #55 to hurt himself; the patient “repeatedly hit his head with a volleyball ...grabbed a basketball to hit his face.” Patient #83’s Face Sheet reflected the 13-year-old was admitted on 04/30/2024 at 1316 and discharged on 05/11/2024 at 1245. Patient #83’s Psychiatric Evaluation dated 05/11/2024, time not legible, reflected the patient was admitted with hearing voices saying, “your time is up.” The patient stated she was “depressed.” Emergency Safety Intervention Justification document dated 04/30/2024 at 1502 reflected the patient tried to attack a peer physically and required a restraint. The document to reflect the patient’s long- and short-term treatment goal and interventions after the emergency behavior intervention was left blank. Patient #83’s Initial Treatment Plan dated 04/30/2024 at 1528 reflected the patient chief complaint of aggression; the patient was placed on suicide and self-harming precautions. The Master Treatment plan was dated 05/06/2024 and did not reflect the emergency behavioral interventions that occurred within two hours of the patient’s admission. Multidisciplinary Treatment Plan Updated dated 05/07/2024 at 0915 did not reflect the patient restraint on 04/30/2024; there was no evidence of nursing interventions to prevent emergency behavior management incidents. Personnel #10 reviewed Patient #55’s and Patient #83’s chart during a personal interview on 5/21/24 at 1549 and acknowledged the findings. Hospital Policy titled Treatment Plan: Interdisciplinary Master Treatment Plan (Reference #1020) was dated 03/01/2024 and noted the policy that patients “have an individualized written treatment plan which is based on interdisciplinary clinical assessments ...directed toward restoring and maintaining optimal levels of physical and psychological functioning as well as preparing for discharge ...” 37325”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 37325 The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). Based on record review and interview the facility failed to complete a discharge plan for 1 of 1 (Patient #4) patients. Finding included: Patient #4 was admitted to the facility on 05/03/24 and discharged on 05/17/27. The Discharge Nursing Assessment/Summary dated 05/17/24 at 08:30 PM does not list a post discharge psychiatric or medical provider. The medical record did not contain a discharge plan. On 05/22/24 the surveyor received via email a discharge plan that reflected ...”D/C (discharge) planner (Personnel #63) was in process of arranging PHP (partial hospitalization program) appt. (appointment) before discharge, however, was notified after the fact that Patient #4 was brought to ...[acute care hospital] for further inpatient care on 05/17/24 ...” During an interview on 05/22/24 at 11:29 AM Personnel #63 stated they had originally started the discharge planning for Patient #4. Personnel #63 stated they had escalated the process up to their supervisor because they were having issues with the discharge plan. Personnel #63 stated the mother had stated they would not pick the patient up from the facility. During an interview on 05/22/24 at 12:01 PM Personnel #66 stated that Patient #4’s mother wanted a referral to a state hospital. Personnel #66 stated they told the mother that the facility did not make referrals to state hospitals. During an interview on 05/22/24 at 12:08 PM Personnel #66 stated Discharge planning was conducted, but acknowleged it was not part of the medical record.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 37325 Based on record review and interview the Registered Nurse (RN) placed 1 0 1 (Patient #1) in seclusion on 04/07/24 without a physician order. Findings included: Patient #1’s Shift Progress Note dated 04/07/24 at 01:50 PM reflected...”Patient became agitated this morning and began to hit and Kick RN and staff. Patient was unable to self-soothe and was walked to the quite room...” However a review of the video footage for 04/07/24 reflected the event happened at 08:36 AM and the patient was placed in the seclusion room with the door closed. A review of the medical record did not evidence an order for the seclusion of Patient #1. During an interview on 04/15/24 at 01:35 PM Personnel #1 verified there was not an order for seclusion for Patient #1 on 04/7/24. The policy titled Emergency Behavioral Interventions: Use of Restraint/ Seclusion dated 07/17/19 reflected...”Physician Order 1. A physician order from a member of the Hospital’s medical staff is required for restraint or seclusion use as an emergency behavior management technique...””

“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: 37325 Based on record review the facility failed to provide a 1-hour face-to-face medical and behavioral evaluation of 1 of 1 (Patient#1) patients after the use of seclusion on 04/07/24. Findings included: Patient #1’s Shift Progress Note dated 04/07/24 at 01:50 PM reflected ...”Patient became agitated this morning and began to hit and kick RN (nurse) and Staff. Patient was unable to self-soothe and was walked to the quite room. However a video review reflected Patient #1 was place in the seclusion room on 04/07/24 at 08:36 AM with the door closed and released at 08:52 AM. Patient #1’s medical record did not reflect a 1-hour face-to-face evaluation was completed for the use of seclusion. During an interview on 0/15/24 at 01:35 PM Personnel #1 verified there was not a restraint/seclusion packet completed for the above incident, therefore there was not a 1-hour face-to-face evaluation completed. The policy titled Emergency Behavioral Interventions: Use of Restraint/Seclusion dated 07/17/19 reflected...Face-to Face Evaluation 1. A physician or their qualified designee, Physician Assistant, Advanced practice Nurse, or QRN) shall conduct a face-to-face evaluation of the individual within one hour following the initiation of restrain or seclusion to personally verify the need for restraint or seclusion...””

“Maintain Clinical Records CFR(s): [Psychiatric hospitals must] Maintain clinical records on all patients, including records sufficient to permit CMS to determine the degree and intensity of treatment furnished to Medicare beneficiaries as specified in §482.61; and This Standard is not met as evidenced by: 37325 Based on record review the facility failed to maintain a clinical record for 1 of 1 (Patient #1) with records sufficient to permit CMS to determine the degree and intensity of treatment furnished. Findings included: A camera review reflected on 04/07/24 at 08:36 AM Patient #1 was placed in the seclusion room with the door closed and released at 08:52 AM. The Shift Progress Note dated 04/07/24 at 01:50 PM reflected ...”Patient became agitated this morning and began to hit and kick RN (nurse) and Staff. Patient was unable to self-soothe and was walked to the quite room. The medical record did not reflect an order for seclusion, a 1-hour face-to-face evaluation after the patient was released, or a notification of a legally authorized representative. The time of the incident was recorded as occurring over five hours after the seclusion occurred. During an interview on 04/07/24 at 01:35 PM Personnel #1 stated if the patient is placed in a seclusion room and the door is left open it is not considered a seclusion and the restraint/seclusion packet does not need to be completed. Personnel #1 stated he reviewed the camera footage for the time charted and could not find the alleged incident on camera. Personnel #1 stated he spoke with the nurse involved and that nurse stated they did not recall the exact time the incident occurred and just put the time that they charted the incident. Personnel #1 stated he reviewed the camera footage and found Patient #1 was escorted to the seclusion room on 04/07/24 at 08:56 AM and the door was closed. Patient #1 remained in the seclusion room until 08:52 AM when they were released from the room. Personnel #1 stated the medical record did not reflect a restraint/seclusion packet. The restrain/seclusion packet includes an order for restraint/seclusion, other methods attempted prior to restraint seclusion, the patient behavior prior to restraint seclusion, the 1-hour face-to-face evaluation, and if a legally authorized representative was notified of the restraint/seclusion.”

“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: 33579 Based on interview, record review, observation the hospital failed 1 of 1 Patient (Patient #1) the right to receive care in a safe setting. Findings Include: Findings Include: Based on Record Review Patient #1 had an x-ray completed on The hospital x-ray results 04/04/2024 at 5:08PM, “Radiopaque density in the stomach appears to be a drywall anchor screw. Soft tissue neck x-ray normal..Dr. reviewed x-rays, feels like this should pass on it & it’s own.” Based on Interview with hospital Staff #3 on 04/09/2024 at 4:30PM, Patient #1 is being monitored daily to ensure that Patient #1 passes items through stool. Based on Record Review interivew the hospital Staff #3 reported, “These incidents are happening during the day time and it is unknown what or how the Patients are being monitored during the day shift. We learn of these events when arrive on the night shift.’ Based on Record Review Patient #1 in the hospital Multidisciplinary Progress Notes 04/01/2024, 1:30PM, “Writer was called to patient’s room. Patient sitting on her bed calm and shaking. Stating she just ‘ate half a bag of the heating pack.’ Patient MD was called and ordered to send Patient out for Evaluation.” During Interview with hospital Staff #1 on 04/09/2024 at 10:00AM Patient #1’s level of observation did not change when the Patient had the heating pad. ‘It appears Patient #1 was in the line of sight reported by staff #1 and not on 1:1 when in the room.” The observation sheets reflected Patient #1 was on 10minute observations.” Based on Observation of the Seclusion Room on the unit there were two red in color drywall screw anchors exposed that could be twisted out and digested by Patient. Staff #1 was present and informed. Staff #1 response was ‘yes.’ During Interview with hospital Staff #6, on 04/09/2024 at 4:40PM Staff #8 was suspended this morning. There is no fullow-up information available to any investigative work or information related to nursing that this staff can provide now that they have been suspended. Thats why they had been suspended. Policy The hospital policy Nursing Services 07/2019, “It is our policy to adhere to the overall hospital mission statement, values and goals of Perimeter Healthcare and various state/federal regulator agencies.” The hospital Policy on Nursing Services Assessment and Reassessment of Patients, 07/2019, reflected, “An accurate record of the patient’s condition, care, and treatment is provided throughout the hospital visit. Screening and admission assessments and histories are completed upon arrival to the hospital and during admission process on the inpatient units The hospital Policy on Nursing Services dated 07/17/2019 reflected, “It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals. The hospital Policy on Neglect 07/2019, Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of healthcare is maximized when addressing issues of conduct of staff.” The hospital Policy on Incident Reporting 07/2019, “The Incident Report is a mechanism for informing administration of the occurrence of circumstances surrounding individual problematic events. An “Incident” is defined as any happening that is not consistent with the normal or usual operations of the hospital and/or department. Injury does not have to occur. The potential for injury and/or property damage is sufficient for an event to be considered an incident. Incidents are reviewed by the Perimeter Healthcare Performance Improvement Committee and referred to other committees as indicated by hospital policy or legal, regulatory or accreditation requirements.””

“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: 33579 Based on Observation, Interview and Record Review the hospital failed 1 of 1 Patient (Patient#1). By failing 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. 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. That clear expectations for safety are established. Findings Include: Based on Record Review Patient #1 had an x-ray completed on The hospital x-ray results 04/04/2024 at 5:08PM, “Radiopaque density in the stomach appears to be a drywall anchor screw. Soft tissue neck x-ray normal..Dr. reviewed x-rays, feels like this should pass on it & it’s own.” Based on Interview with hospital Staff #3 on 04/09/2024 at 4:30PM, Patient #1 is being monitored daily to ensure that Patient #1 passes items through stool. Based on Record Review interivew the hospital Staff #3 reported, “These incidents are happening during the day time and it is unknown what or how the Patients are being monitored during the day shift. We learn of these events when arrive on the night shift.’ Based on Record Review Patient #1 in the hospital Multidisciplinary Progress Notes 04/01/2024, 1:30PM, “Writer was called to patient’s room. Patient sitting on her bed calm and shaking. Stating she just ‘ate half a bag of the heating pack.’ Patient MD was called and ordered to send Patient out for Evaluation.” During Interview with hospital Staff #1 on 04/09/2024 at 10:00AM Patient #1’s level of observation did not change when the Patient had the heating pad. ‘It appears Patient #1 was in the line of sight reported by staff #1 and not on 1:1 when in the room.” The observation sheets reflected Patient #1 was on 10minute observations.” Based on Observation of the Seclusion Room on the unit there were two red in color drywall screw anchors exposed that could be twisted out and digested by Patient. Staff #1 was present and informed. Staff #1 response was ‘yes.’ During Interview with hospital Staff #6, on 04/09/2024 at 4:40PM Staff #8 was suspended this morning. There is no fullow-up information available to any investigative work or information related to nursing that this staff can provide now that they have been suspended. Thats why they had been suspended. Policy The hospital policy Nursing Services 07/2019, “It is our policy to adhere to the overall hospital mission statement, values and goals of Perimeter Healthcare and various state/federal regulator agencies.” The hospital Policy on Nursing Services Assessment and Reassessment of Patients, 07/2019, reflected, “An accurate record of the patient’s condition, care, and treatment is provided throughout the hospital visit. Screening and admission assessments and histories are completed upon arrival to the hospital and during admission process on the inpatient units The hospital Policy on Nursing Services dated 07/17/2019 reflected, “It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals. The hospital Policy on Neglect 07/2019, Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of healthcare is maximized when addressing issues of conduct of staff.” The hospital Policy on Incident Reporting 07/2019, “The Incident Report is a mechanism for informing administration of the occurrence of circumstances surrounding individual problematic events. An “Incident” is defined as any happening that is not consistent with the normal or usual operations of the hospital and/or department. Injury does not have to occur. The potential for injury and/or property damage is sufficient for an event to be considered an incident. Incidents are reviewed by the Perimeter Healthcare Performance Improvement Committee and referred to other committees as indicated by hospital policy or legal, regulatory or accreditation requirements.””

“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: 33579 Based on Record Review and Interview the hospital failed 1 of 1 Patient (Patient #1) by failing to ensure the patient has the right to be free free from all forms of abuse or harassment. Findings Include: During Record Review, the hospital Multidisciplinary Progress Note 03/26/2024, 8:55PM, “Patient #1 reported that he was attacked by peer while in the bathroom, but patient is unable to identify who the peer is.” During Record Review, the hospital Multidisciplinary Progress Notes 03/26/2024 at 8:55PM, “Patient #2 reports witnessing another patient (Patient #4) attack a peer (Patient #1) . During Record Review, The Shift Progress Note 03/26/2024 at 8:55PM, ‘Peer accused Patient of attacking another Patient.’ Patient #3 was describing Patient #4 attacking Patient #1. During Record Review the Hospital Incident Log reflected 4 individuals listed on the log on the same housing unit at approximately the same date 03/26/2024 and same time 8:20PM. (Patient #1, Patient #2, Patient #3, and Patient #4). During Interview with Hospital Staff #1 and Staff #6 on 04/09/2024, “The DON has been placed on suspension this morning. There is no way to contact the DON now, since being placed on suspension. Staff #6 was advised that there is no report of an investigation and the hospital is not following its own policy. Staff #6 had no further response. Videofootage was not provided for review as it relates to this incident.” Policy The hospital Policy on Patient Rights dated 07/17/2019, reflected, “The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations.””

“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: 33579 Based on Record Review, and Interview the hospital failed 1 of 1 Patient (Patient #1) 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 Patient Safety, Internal Investigations, education and documentation of Patient abuse and neglect. Findings Include: During Record Review, the hospital Multidisciplinary Progress Note 03/26/2024, 8:55PM, “Patient #1 reported that he was attacked by peer while in the bathroom, but patient is unable to identify who the peer is.” During Record Review, the hospital Multidisciplinary Progress Notes 03/26/2024 at 8:55PM, “Patient #2 reports witnessing another patient (Patient #4) attack a peer (Patient #1) . During Record Review, The Shift Progress Note 03/26/2024 at 8:55PM, ‘Peer accused Patient of attacking another Patient.’ Patient #3 was describing Patient #4 attacking Patient #1. During Record Review the Hospital Incident Log reflected 4 individuals listed on the log on the same housing unit at approximately the same date 03/26/2024 and same time 8:20PM. (Patient #1, Patient #2, Patient #3, and Patient #4). During Interview with Hospital Staff #1 and Staff #6 on 04/09/2024, “The DON has been placed on suspension this morning. There is no way to contact the DON now, since being placed on suspension. Staff #6 was advised that there is no report of an investigation and the hospital is not following its own policy. Staff #6 had no further response. Videofootage was not provided for review as it relates to this incident.” Policy The hospital Policy on Patient Rights dated 07/17/2019, reflected, “The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations.””

“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: 33579 Based on Record Review, Interview and Observation the hospital failed Patient #1 and Patient #12 by failing to ensure the Patient was kept in a safe setting. Findings Include: During Record Review the hospital Admission Nursing Assessment, 02/15/2024 at 0402AM, “Patient is Lactose Intolerant.” Patient #1 had no record of follow up in the medical record indicating the patient was cared for or treated. During Interview the hospital Staff #1 and Staff #2 was unaware that Patient #1 was Lactose Intolerant. During Interview with hospital Staff #4 and Record Review 03/13/2024 at 3:30 PM provided the cafeteria menu’s during the time Patient #1 was admitted into the hospital. There was an opportunity at each meal for Patient #1 to have non-dairy products. Patient #1 was noted to be on the Lactose Intolerant meal plan, but Staff #1 reported Patient #1 was on a regular diet and could not control what Patient #1 did once on the table. During Observation Patient #1 was observered seated in the milieu with peers. Patient #12 was down the hallway with Staff #3. Patient #1 appears to hear Patient #2 kicking doors and yelling in the hallway. Patient #1 stood up and ran down the hallwayand tackled Patient #12. There is no documentation in Patient #1 or Patient #2’s medical record addressing this situation. The patients were quickly separated, and there were no visible injuries noted on this observation. The incident occured on 02/20/2023 at 6:35PM. Policy The hospital policy on Abuse, Neglect, Exploitation, Unethical or Unprofessional Conduct, dated 07/17/2019 reflected, “Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assesses the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care services providers will immediately report to the appropriate supervisors, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. The hospital Policy on Patient Rights dated 07/17/2019, reflected, “The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations.” The hospital Policy on Nursing Services 07/17/2019 reflected, “An accurate record of the patient’s condition, care, and treatment is provided throughout the hospital visit. Screening and admission assessment and histories are completed upon arrival to the hospital and during the admission process on the inpatient units. Reassessments are documented when there is a significant change in patient status. Post procedure, etc. Patient information obtained, during reassessments will be post procedure, etc. Patient information obtained during reassessments will be documented in the patient’s medical record.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 37325 Based on record review and interview the facility failed to protect the rights to receive care in a safe setting for 10 of 10 (Patients #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11)) patients. 1. On 03/05/24 Patient #8 busted through the glass of 3 sets of doors and was able to elope the facility with Patient #7, Patient #9, Patient #10 and Patient #11. The facility was located approximately 200 yards from State Highway 287 a 3-lane highway with a speed limit of 65mph and an average annual daily traffic of 4,799 cars (Traffic Count Database System (TCDS) (ms2soft.com). All patients were returned to the facility on 03/05/24 about 1 hour and 20 minutes after they eloped. 2. On 03/09/24 Patient #2 jumped over the nurse’s station and pulled the fire alarm which released all the magnetic locks on the facility’s doors. Patient #2, Patient #3, and Patient #6 were able to elope from the facility via a courtyard gate. The patients returned to the facility on their own approximate 30 minutes after they eloped. A day later, on 03/10/24, Patient #2 again jumped over the nurse’s station and pulled the fire alarm eloping the facility with Patient #3, Patient #4 and Patient #5. The patients were returned to the facility by the police approximately 1 hour and 30 minutes after they eloped. The facility’s plan of correction was to place an employee in front of the fire alarm pull until the locked fire alarm covers could be installed. No employee was observed in front of the fire alarm pull during a tour of the facility on 03/13/24 at 12:35 PM and the fire alarm remained accessible to Patient #4 and Patient #5 who were still admitted to the facility. In addition, the fire alarm code had been changed by the previous environment of care director and the staff were unable to turn the fire alarm off leaving the magnetic locks released until the alarm could be turned off on 03/09/24. Cross Refer Tag A0144”

“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: 37325 Based on record review and interview the facility failed to protect the rights to receive care in a safe setting for 10 of 10 (Patients #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11)) patients. 1. On 03/05/24 Patient #8, an adolescent boy busted out the glass of 3 sets of doors and was able to elope the facility with Patient #7, Patient #9, Patient #10, and Patient #11. 2. On 03/09/24 Patient #2 jumped over the nurse’s station and pulled the fire alarm. This released all the magnetic locks on the facility’s doors. Patient #2, Patient #3, and Patient #6 were able to elope from the facility via a courtyard gate. On 03/10/24 Patient #2 again jumped over the nurse’s station and pulled the fire alarm eloping from the facility with Patient #3, Patient #4 and Patient #5. Findings included: 1. Patient #7, a 17-year-old male, was admitted to the facility on 02/29/24 for homicidal ideation, suicidal ideation with a plan, and running away from home. Patient #7 was initially placed on elopement precautions and unit restrictions. The Physician’s orders for 03/01/24 through 03/05/24 did not evidence an order to continue or discontinue the unit restricts. Patient #8, a 17-year-old male, was admitted to the facility on 03/04/24 from a juvenile detention center due to aggression/violence via punching and kicking things. The Physician’s Orders did not evidence an order for unit restrictions or elopement precautions. Patient #9, a 16-year-old male, was admitted to the facility on 02/28/24 for eloping from school daily, drug, and tobacco use. Patient #9 was initially placed on elopement precautions and unit restriction. The Physician’s Orders reflected on 03/01/24 and 03/02/24 the order for elopement precautions was renewed. The Physician’s Orders on 03/03/04 through 03/05/24 did not evidence an order to continue or discontinue the elopement precautions. Patient # 10, a 15-year-old-male, was admitted to the facility on 02/20/24 from a juvenile detention center due to suspected psychosis. Patient # 10 was initially placed on elopement precautions and unit restrictions. The Physician’s Orders for 03/02/24 and 03/03/24 evidenced an order for elopement precaution. The Physician’s Orders for 03/04/24 and 03/05/24 did not evidence an order to continue or discontinue any type of precautions. Patient # 11, a 13-year-old male. Was admitted to the facility on 03/03/24 via a detention warrant for suicidal ideation. Patient # 11 was not initially placed on elopement precautions or unit restrictions. The Physician’s Orders for 03/04/24 did not evidence an order to continue or discontinue any type of precautions. The Physician’s Orders for 03/05/24 did not evidence an order for elopement precautions or unit restrictions until after the patient eloped from the facility. The camera reviewed reflected on 03/05/24 Patient #7, Patient #8, Patient #9, Patient # 10, and Patient # 11 were taken to the cafeteria to eat at around 06:17 PM. At 06:23 PM Patient # 8 flips over a table in the cafeteria, that is open to the hallway without doors, then walks into the hallway and flips over another table. At 06:24 PM Patient #8 breaks through a glass door and proceeds across a courtyard to another set of glass doors. Patient #8 breaks through that door and calls for other patients to follow him. At 06:26 Patient #8 breaks the glass in a third door that leads outside the hospital and Patient #7, Patient #9, Patient #10, and Patient #11 follow Patient #8 out of the facility. All 5 male patients were returned to the facility by police on 03/05/24 about 1 hour and 20 minutes after they eloped. . During an interview on 03/13/24 at 12:35 PM Personnel #1 stated that if a patient is on elopement precautions the policy states, they should also be on unit restrictions. Personnel #1 stated the patient’s level of precautions should be either reordered or discontinued every day. The policy titled Precaution Interventions, revised on 02/12/24 reflected ...Procedure ...All precautions must be renewed every 24 hours ...Elopement ...Must be on Unit Restrictions ...” 2. Patient #2, a 17-year-old female, was admitted to the facility on 03/03/24 for suicidal ideation and eloping from a residential treatment center. Patient #2 was not initially placed on elopement precautions or unit restrictions. The Physician’s orders for 03/09/24 evidenced the patient was placed on elopement precautions after they eloped from the facility that day. The Physician’s orders on 03/10/24 evidenced the elopement precautions had been continued. Patient #3, a 14-year-old female, was admitted to the facility on 03/08/24. The patient had been admitted to another facility 5 days prior to this admission for suicidal ideation and elopement. Patient #3 had been discharged from the other facility on 03/08/24 and within 2 hours made suicidal, self-harm, and elopement statements. Patient #3 was initially placed on elopement precautions and unit restrictions. The Physician’s Orders on 03/09/24 did not evidence an order to continue or discontinue elopement precautions and unit restrictions. The Physician’s Orders evidenced the elopement precautions had been continued on 03/10/24. Patient #4, a 14-year-old female, was admitted to the facility on 03/09/24 for an attempted suicide. Patient #4 was not initially placed on elopement precautions or unit restrictions. The Physician’s Orders on 03/11/24 evidenced the patient had been placed on elopement precautions. The medical record did not evidence an order for elopement precautions on 03/10/24 after the patient was returned to the facility after an elopement. Patient #5, a 16-year-old female, was admitted to the facility on 03/02/24 after multiple incidents of sneaking out to use substances and sneaking her 20-year-old boyfriend into the family home. Patient #5 was not initially placed on elopement precautions or unit restrictions. The medical record did not evidence an order for elopement precautions on 03/10/24 after the patient was returned to the facility after an elopement. The 03/11/24 Physician’s Orders evidenced Patient #5 was placed on unit restrictions but not elopement precautions. The Physician’s orders for 03/12/24 and 03/13/24 did not evidence an order to continue or discontinue the unit restrictions; no elopement precautions were ordered. Patient #6, a 16-year-old female, was admitted to the facility on 02/29/24 for suicidal ideation, self-harm, and medication noncompliance. Patient #6 was initially placed on elopement precautions and unit restrictions. The Physician’s Orders from 03/01/24 through 03/04/24 did not evidence an order to continue or discontinue the elopement precautions or unit restrictions. The Physician’s Orders dated 03/05/24 evidenced an order for elopement precautions. The Physician’s Orders dated 03/06/24 Through 03/09/24 did not evidence an order to continue or discontinue the elopement precautions. Patient #6 was placed on elopement precautions on 03/09/24 after eloping from the facility. The Physician’s Orders dated 03/11/24 through 03/13/24 did not evidence an order to continue or discontinue the elopement precautions. The camera review for 03/09/24 reflected at 07:20 PM Patient #2 pulled a chair next to the nurse’s station, jumped into the nurse’s station, and pulled the fire alarm. Patient #2 and Patient #3 exited the adolescent girl’s unit into a hallway and attempted to enter the lobby. Patient #2 and Patient #3 proceeded to a closed unit and Patient #3 pulled a second fire alarm. Patient #2 and Patient #3 were found hiding in the nurse’s station of the closed unit and were escorted back to their unit. Patient #2 and Patient #3 then ran across the adolescent girl’s unit out an exit door to a courtyard and eloped through an open gate. At 08:11 PM Patient #6 then runs through the exit door and eloped from the facility. Patient #6 then walked to the front of the facility and was let back in. Patient #2 and Patient #3 returned to the facility on their own at 08:00 PM on 03/09/24. The camera review for 03/10/24 reflected on 03/10/24 at 08:44 PM Patient #2 jumped over the nurse’s station and pulled the fire alarm. At 08:45 PM Patient #2, Patient #3, Patient #4 and Patient #5 run over the staff guarding the exit door and elope from the facility through the courtyard. All patients returned to the facility 30 minutes later. During a complaint survey on 03/13/24 Personnel #1 stated the plan of correction was to place an employee in front of the fire alarm pull until the locked fire alarm covers could be installed. During a tour of the facility on 03/13/24 at 12:35 PM there was not an employee stationed in front of the fire alarm pull. During a facility tour on 03/13/24 at 12:35 PM Personnel #1 stated when Patient #2 pulled the fire alarm all magnetic door locks released and Patient #2, Patient #3 and Patient #6 eloped from the facility. Personnel #1 stated the previous Environment of Care Coordinator had changed the code to turn off the fire alarm and all the doors remained unlocked until the alarm could be turned off. The facility was able to fix that issue on 03/09/24. Personnel #1 stated the facility had ordered locking fire alarm covers but they were not installed yet. Personnel #1 stated the facility had placed an employee to stand by the fire alarm pull to stop the patients from pulling the alarm and eloping. While on the adolescent girl’s unit on 03/13/24 at 12:35 PM this surveyor observed no employes were standing next to the fire alarm. Personnel #1 stated that the patient that had been pulling the fire alarm had been discharged from the facility, so they were no longer stationing an employee in front of the fire alarm. This surveyor confirmed with Personnel #1 that at least 2 of the 5 girl’s that had eloped due to the fire alarm being pulled were still admitted to the facility.”