Eastern State Hospital

“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: 43948 . Based on interviews, record review, and review of the hospital’s policies and procedures, the hospital failed to ensure that staff followed policies and procedures for the use of seclusion and/or restraint, including obtaining a provider order for the type of restrictive intervention/s (physical hold, seclusion, and/or restraint) used for 2 of 4 patients (Patients #1 and #4) (Item #1), and documenting the start and/or end times of the seclusion/restraint, 3 of 4 patients (Patients #1, #2, and #4) (Item #2). Failure to obtain an order for each instance of restraint and/or seclusion and failure to document the restraint/seclusion stand and end times places the patient at risk for psychological harm, loss of dignity, and violation of patient rights. Findings included: Item #1 - Provider’s orders for seclusion and/or restraint interventions 1. Document review of the hospital’s policy titled, “BHA Seclusion and Restraint,” policy number BHA 10.34, approval date 08/13/24, showed the following: a. The purpose of the policy is to follow the credentialing body’s philosophy when applicable, ensuring that hospital staff follows the appropriate indications and procedures governing the use of seclusion and restraint. b. A written, telephone, or electronic order for seclusion and/or restraint must be obtained immediately from the attending psychiatric practitioner or designated licensed practitioner (LIP). c. Documentation of restraint or seclusion in the patient/resident medical record shall be consistent with the facility’s legal, licensing, or accreditation authority such as Joint Commission Standard PC.03.05.15. Patient #1 2. The Investigator reviewed the medical record for Patient #1, who was admitted on 08/14/25. The review showed the following: a. Between 11/24/25 and 01/26/26, the patient had been placed into seclusion and/or restraint 20 times. The Investigator found that for 3 of 20 seclusion and/or restraint incidents, the provider failed to write orders for each of the interventions initiated during the incidents. b. On 11/24/25 at 3:10 PM, the provider wrote an order to place the patient into seclusion due to “danger to others.” Staff documented that the patient was highly agitated, yelling, and threatening staff. Nursing staff documented on the Seclusion Record that the patient was taken to the seclusion room using a manual/physical hold. There was no provider order for the manual/physical hold. c. On 12/02/25 at 8:30 AM, the provider wrote an order for a manual/physical hold due to “danger to others.” Staff documented that the patient was posturing and making threats. Nursing staff documented on the Seclusion Record that staff initiated a physical hold and transferred the patient to the seclusion room. There was no provider order for seclusion. d. On 12/14/25 at 6:10 PM, the provider wrote an order for seclusion due to “danger to others.” Staff documented that the patient was threatening a peer. Nursing staff documented on the Seclusion Record that the patient was threatening to punch staff and throw hot water at them. Staff failed to document evidence that the patient walked willingly to the seclusion room. There was no provider order for the manual/physical hold. Patient #4 3. The Investigator reviewed the medical record for Patient #4, who was admitted on 11/18/24. The review showed that on 12/20/25 at 5:40 PM, the provider wrote an order for a restrictive intervention due to “danger to others and danger to self.” The provider failed to indicate the restrictive intervention to be implemented. The provider left the option (physical/manual, seclusion, and restraint) blank. Item #2 - Documentation of initiation and release times for seclusion/restraint incidents 1. Review of the hospital’s document from the Medical Record Manual titled, “Guidelines for Seclusion or Restraint Records,” no policy number, effective 05/23, showed the following: a. The purpose of the document was to provide guidelines for documenting the need, use, monitoring and effectiveness of seclusion and restraints. b. Nursing documentation in the seclusion record form includes: i. Check the initial time in for the initiation of the restrictive event. Time begins at the start of the physical/manual hold to place an individual into seclusion and restraint. ii. At the time of the release, document the date and time. iii. Describe the patient’s behavior at the time of release. c. After the patient is removed from seclusion or restraint, ensure all forms are signed, dated, and completed according to hospital guidelines and filed in the Seclusion/Restraint section of the medical record. Patient #1 2. The Investigator reviewed the medical record for Patient #1, who was admitted on 08/14/25. The review showed the following: a. On 12/02/25 at 8:15 AM, the provider wrote an order for a manual/physical hold due to “danger to others.” Staff failed to document the patient’s release from the manual hold. b. On 12/09/25 at 7:45 AM, the provider wrote an order for a manual/physical hold and seclusion due to “danger to others.” Staff failed to document when the patient was released from the manual hold and failed to document the time the patient was released from seclusion. c. On 12/11/25 at 10:05 AM, the provider wrote an order for a manual/physical hold, seclusion, and the restraint chair due to “danger to others.” Staff failed to document the patient’s release from the manual hold, seclusion, and the restraint chair. d. On 12/24/25 at 6:00 PM, the provider wrote an order for a manual/physical hold due to “danger to others.” The Investigator failed to find evidence of a Seclusion Record for the incident, including documentation of the time the intervention was initiated or when the patient was released from the hold. e. On 01/24/26 at 9:25 AM, the provider wrote an order for a manual/physical hold due to “danger to others.” The Investigator failed to find evidence of a Seclusion Record for the incident, including documentation of the time the intervention was initiated or when the patient was released from the hold. Patient #2 3. The Investigator reviewed the medical record for Patient #2 who was admitted on 05/27/25. The review showed the following: a. On 11/24/25 at 8:25 AM, the provider wrote an order for a manual/physical hold due to “danger to others.” b. On 11/27/25 at 2:20 PM, the provider wrote an order for a manual/physical hold due to “danger to others.” c. On 11/28/25 at 3:45 PM, the provider wrote an order for a manual/physical hold due to “danger to others.” d. The Investigator failed to find evidence of Seclusion Records for the incidents, including documentation of the time the interventions were initiated or when the patient was released from the hold. Patient #4 4. The Investigator reviewed the medical record for Patient #4, who was admitted on 11/18/24. The review showed the following: a. On 01/07/26 at 8:00 PM, the provider wrote an order for a manual/physical hold due to “danger to others and danger to self.” b. The Investigator failed to find evidence of a Seclusion Records for the incident, including documentation of the time the intervention was initiated or when the patient was released from the hold. 5. On 01/27/26 at 2:15 PM, the Investigator interviewed a registered nurse (Staff #6) about the missing and incomplete seclusion and restraint documentation. Staff #6 stated that the facility has a checklist for staff to use when auditing the seclusion and restraint documents, and each restraint and seclusion incident is reviewed by the night shift nursing staff to ensure that the documentation is complete. 6. On 02/17/26 at 1:15 PM, during an interview with the Investigator, the Chief Quality Officer (Staff #1) verified the Investigator’s findings of the missing seclusion and restraint documentation. Staff #1 stated that the hospital was working with the nursing staff to ensure that the incidents are documented in their entirety. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 43948 . Based on interview, record review, and review of policies and procedures, the hospital failed to ensure that providers did not write orders for seclusion or restraint as a standing order or on an as-needed basis, as demonstrated by 1 of 4 medical records reviewed (Patient #1). Failure to follow approved policies and procedures for seclusion and restraint use places the patient at risk for psychological harm, loss of dignity, and is a violation of patients’ rights. Findings included: 1. Document review of the hospital’s policy and procedure titled, “BHA 10.34 Seclusion and Restraint,” policy number BHA 10.34, approval date 08/13/24, showed the following: a. All patients/residents have the right to be free from physical or mental abuse and corporal punishment. All patients/residents have the right to be free from restraint and seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. b. Seclusion or restraint is used only in situations where the patient/resident presents an immediate/imminent physical danger to themselves and/or others and less restrictive interventions are not effective in remedying the danger. c. Standing orders or as needed orders for restraint or seclusion are not allowed. Document Review of the hospital’s policy and procedure titled, “Interdisciplinary Protocol for Seclusion and Restraint,” no policy number, approval date 05/23, showed the following: a. All patients have the right to be free from restraint or seclusion, in 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 and must be discontinued at the earliest possible time. b.Seclusion and restraint may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. c. Verbal threats of harm and physical posturing do not by themselves present as immediate danger. These behaviors require de-escalation interventions with less restrictive alternatives to reduce the potential of actual physical violence and/or destruction of property. Patient #1 2. The Investigator reviewed the medical record for Patient #1, who was admitted on 08/14/25. The Investigator found 4 behavioral support plans. The review showed the following: a. The first behavioral support plan dated 08/27/25, focused on bullying behaviors and failure to redirect for safety. Targeted behaviors included name calling, cussing at people, refusing redirection, or stating he wanted to fight or be hit by peers. The behavioral support plan outlined the staff’s response to incidents of escalation. For the first redirection, remind the patient of a music reward, such as listening to Ann Murray, and the 3 rules he must follow. State that the redirection is meant to keep him safe. Staff are directed to thank the patient if he stops the behavior and to give him positive attention. The second redirection, if the patient continues to antagonize his peers, is to inform him he must stop the behavior, or he will go into seclusion until he can calm himself down. Staff are directed that if the patient’s target behavior continues, they are to escort the patient to seclusion immediately. b. The second behavioral support plan, not dated, directed staff to engage the patient immediately if he gets excited, trying to calm or redirect him from agitating the milieu. If the behavior is unsafe, direct him to the seclusion room. Do not give multiple warnings, escort him to seclusion if safety requires. The patient gets two warnings before implementing seclusion protocol. On the third redirection, implement locked or unlocked seclusion protocol based on nursing discretion. c. The third behavioral support plan dated 09/19/25, was written when the patient was transferred to a new unit (3S2). The targeted behaviors, listed in order of potential severity of outcome, included bullying peers, pretending distress, self-injurious behaviors, and poor social boundaries. When responding to incidents of bullying peers, staff are directed to attempt to keep the patient’s energy level as close to baseline as possible. Intervene quickly at the earliest sign of escalation. If after initial intervention, the patient continues to escalate after the second redirection, escort the patient to seclusion immediately and follow seclusion protocols to determine when it is safe to allow him to rejoin the milieu. d. A fourth behavioral support plan dated 12/17/25, included two targeted behaviors and interventions. For targeted behavior #1 (physical and verbal aggression, including threats, racist/abusive language, spitting, yelling, assault) and targeted behavior #2 (inappropriate sexual comments and behaviors), staff were directed to increase staff presence, with only one staff speaking to the patient to avoid confusion. Staff should maintain a safe distance and offer to take the patient to the quiet room. Staff are instructed to provide two prompts for quick redirection to either the quiet room or seclusion room. Nursing or medical provider to decide if the seclusion will be locked or unlocked. 3. The review showed that the 4 behavioral support plans directed staff to place Patient #1 into seclusion, as needed, after 2 unsuccessful attempts to redirect the patient’s targeted behaviors. The medical record showed that between 11/24/25 and 01/26/26, showed that the patient had been placed into seclusion and/or restraint 20 times: 11/24/25, 12/02/25, 12/05/25, 12/08/25, 12/09/25, 12/10/25, 12/11/25 (two incidents), 12/14/25, 12/15/25, 12/18/25 (two incidents), 12/19/25, 12/21/25, 12/23/25, 12/24/25, 01/11/26, 01/12/26, and 01/24/26. 4. On 01/27/26 at 1:00 PM, during an interview with the Investigator, a registerd nurse (Staff #6) stated that the nurses follow the patient’s behavioral support plans. When a patient is exhibiting targeted behaviors, such as yelling and threatening, they will attempt to calm the patient down. If the patient continues to escalate and staff cannot redirect the patient, the staff will walk the patient to the seclusion room. If the patient refuses to go with staff, they may perform a manual hold to escort them to the seclusion room. Staff #6 stated that the charge nurse makes the decision to place the patient in seclusion or the restraint chair and calls the provider for orders. 5. On 02/17/26 at 1:30 PM, during an interview with the Investigator, the Certification and Accreditation Manager (Staff #2) stated that Patient #1 was currently admitted to the Westlake Campus of the hospital on the Habilitative Mental Health (HMH) ward (for patients who live with both mental illness and developmental delay). Staff #2 stated that the staff working with this patient population currently did not receive any specialized training to treat the patients with developmental delay admitted to the HMH ward. Staff #2 stated that staff is directed to use the behavioral support plans that are in place for each patient. Staff #2 stated that the hospital was currently initiating specialized training for the staff working on the HMH ward. 6. On 02/17/26 at 1:00 PM, during an interview with the Investigator, the Quality Officer (Staff #1) and the Director of Social Work (Staff #7) verified that the behavioral support plans for Patient #1 directed staff to place the patient into seclusion after 2 unsuccessful attempts to redirect. Staff #1 agreeded that the behavioral support plans directing staff to place patient in restraint/seclusion after two failed attempts at redirection were essentially PRN restraint orders, and that cussing was not a valid reason for restraint/seclusion. Staff #1 stated that they are working with the nursing staff to better document the behaviors that lead to the seclusion and restraint events. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 43948 . Based on observations, interviews, record review, and review of the hospital’s policies and procedures, the hospital failed to consider the effectiveness of less restrictive interventions before applying seclusion and/or restraints for the management of violent or self-destructive behaviors for 4 of the 8 records reviewed (Patients #1, #2, #5, and #8). Failure to utilize less restrictive alternatives to seclusion and/or restraints for the management of violent or self-destructive behaviors places the patient at risk for physical and psychological harm, loss of dignity, and violation of patient rights. Findings included: 1. Document review of the hospital’s policy titled, “BHA Seclusion and Restraint,” policy number BHA 10.34, approval date 08/13/24, showed the following: a. All patients have the right to be free from physical or mental abuse and corporal punishment. All patients have the right to be free from restraint and seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. b. Seclusion or restraint is used only in situations where the patient presents an immediate/imminent physical danger to themselves and/or others and less restrictive interventions are not effective to remedy the danger. Document review of the hospital’s training document titled, “DSHS BHA Eastern State Hospital (ESH) Regulatory Standards for Seclusion/Restraint 2025,” no document number, not dated, showed the following: a. Seclusion may only be used for the management of violent or self-destructive behavior. b. Restraint may be physical (any method to restrict movement) or chemical (a drug or medication used to manage a person’s behavior or restrict their freedom of movement). c. Seclusion and/or restraint may only be used when a patient presents as an immediate danger by an actual physical act of violence toward self or others, or actual destruction of property. d. Examples of what is not considered immediate danger: i. A patient punches a wall and goes to their room. ii. A patient postures at another patient and goes to their room. iii. A patient is cursing aggressively, threatening a peer or staff, with no physical act of violence. iv. A patient throws food and/or water and walks to their room. e. Sometimes de-escalation interventions or less restrictive alternatives do not resolve the immediate danger. f. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. Patient #1 2. The Investigator reviewed the medical record for Patient #1 who was admitted on 03/27/25. The review showed the following: a. On 03/30/25 at 6:10 AM, Patient #1 was placed in seclusion. i. On the Seclusion/Restraint Treatment Order dated 03/30/25, the provider documented that the reason for the intervention was due to the patient “threatening others.” The provider failed to document the “restrictive intervention” to be implemented for the order. This section of the order was left blank. ii. On the Seclusion Record dated 03/30/25, nursing staff documented that the patient was placed into seclusion at 6:10 AM. Staff documented that the patient came out of their room, aggressively pushed past staff, and was not redirectable. The patient was tense, uncooperative, and unpredictable. The staff was able to guide the patient to the seclusion room with minimal touching. iii. On the Seclusion Record dated 03/30/25, nursing staff documented that prior to the intervention, staff attempted the following less restrictive alternatives: Validate, Defer, Suggest, Prompt (VDSP), safety plan interventions, redirection, and meeting patient’s needs. Nursing staff documented that during the restrictive intervention, staff attempted the following less restrictive alternatives: meeting patient’s needs. Nursing staff also documented that due to the immediate danger, less restrictive measures were not implemented. iv. The patient was released from seclusion on 03/30/25 at 8:00 AM. After the patient’s release, he was observed calmly pacing in his room, mumbling. b. On 03/31/25 at 9:03 PM, the patient was placed in seclusion. i. On the Seclusion/Restraint Treatment Order dated 03/31/25, the provider documented that the reason for the intervention was due to the patient “pushing through staff, intrusive, not re-directable, growing aggressive.” ii. On the Seclusion Record dated 03/31/25, nursing staff documented that prior to the intervention, the patient was on assault precautions and 1:1 observation. Nursing staff documented that multiple staff were following the patient who was pacing outside of the double door restriction. The patient was checking locks and refusing redirection. The patient pushed through staff attempting to enter a peer’s room. The patient was growing more aggressive and resistant. iii. On the Seclusion Record dated 03/31/25, nursing staff documented that prior to the intervention, staff attempted the following less restrictive alternatives: redirection and meeting patients’ needs. Nursing staff did not document the use of less restrictive intervention during the intervention. iv. The patient was released from seclusion on 04/02/25 at 11:10 AM. After the patient’s release, he was observed resting in his room. c. The Investigators’ review of the seclusion and restraint incidents that occurred on 03/30/25 at 6:10 AM and 03/31/25 at 9:03, found no evidence documenting the need for implementing seclusion and/or restraint. The hospital staff documented that the patient was not redirectable, posturing, intrusive, resistant, tense, and threating, however, staff failed to document evidence of behaviors where the patient was presented as an immediate/imminent physical danger to himself or others. Patient #2 3. The Investigator reviewed the medical record for Patient #2 who was admitted on 04/15/25. The review showed the following: a. On 06/14/25 at 7:45 PM, Patient #2 was placed in seclusion. i. On the Seclusion/Restraint Treatment Order dated 06/14/25, the provider documented that the reason for the intervention was due to the patient “threatening to assault” a peer. ii. On the Seclusion Record dated 06/14/25, nursing staff documented that the patient calmly walked into the dining room and got some snacks. The patient turned around and threw the snacks at a peer whom he was targeting earlier in the day. iii. On the Seclusion Record dated 06/14/25, nursing staff documented that prior to the intervention, staff attempted the following less restrictive alternatives: redirection and safety plan interventions, however staff also checked the box for “due to immediate danger less restrictive measures could not be implemented.” Nursing staff did not document the use of less restrictive intervention during the intervention. iv. The patient was released from seclusion on 06/15/25 at 3:00 PM. After the patient’s release, he was observed resting in his room. b. The Investigators’ review of the seclusion and restraint incident that occurred on 06/14/25 at 7:45 PM found no documentation showing the need for the implimentation of seclusion and/or restraint. The hospital staff documented that the patient was threatening and had thrown snacks at a peer, however, staff failed to document evidence of behaviors where the patient was presented as an immediate/imminent physical danger to himself or others. Patient #5 4. The Investigator reviewed the medical record for Patient #5 who was admitted on 04/23/25. The review showed the following: a. On 04/23/25 at 12:04 PM, Patient #5 was placed in seclusion. i. On the Seclusion/Restraint Treatment Order dated 04/23/25, the provider documented that the reason for the intervention was due to the patient spitting, hitting, and kicking staff. ii. On the Seclusion Record dated 04/23/25, nursing staff documented that upon admission the patient initially refused to get out of the police car, but eventually agreed to walk to the ward. Staff showed the patient the bathroom, helped her with a shower, and provided her with clean clothes. When staff assisted the patient to dress, the patient was cursing, aggressive, and slapping staff. The staff walked the patient to the seclusion room. iii. On the Seclusion Record dated 04/23/25, nursing staff documented that prior to the intervention, staff attempted the following less restrictive alternatives: VDSP and redirection. Staff documented that due to immediate danger, less restrictive measures could not be implemented during the intervention. iv. The patient was released from seclusion on 05/07/25 at 1:10 PM. After the patient’s release, she was observed resting in her room. b. On 05/07/25 at 3:00 PM, Patient #5 was placed in seclusion. i. On the Seclusion/Restraint Treatment Order dated 05/07/25, the provider documented that the reason for the intervention was due to the patients’ inability to “safety plan” and her previous aggressive assaultive behavior. ii. On the Seclusion Record dated 05/07/25, nursing staff documented the patient was labile, disorganized and verbally aggressive. iii. On the Seclusion Record dated 05/07/25, nursing staff failed to document any less restrictive alternatives prior to the intervention. Staff documented that due to immediate danger, less restrictive measures could not be implemented during the intervention. Nursing staff documented that during the restrictive intervention, staff attempted the following less restrictive alternatives: active listening and meeting patient’s needs. However, nursing staff also documented that due to the immediate danger, less restrictive measures were not implemented during the intervention. iv. The patient was released from seclusion on 05/09/25 at 1:13 PM. After the patient’s release, she was observed calmly interacting with others. c. On 05/13/25 at 8:50 AM, Patient #5 was placed in seclusion. i. On the Seclusion/Restraint Treatment Order dated 05/13/25, the provider documented that the reason for the intervention was due to the patients’ assaultive behavior towards other patients and staff and the patient’s unwillingness to plan for safety. ii. On the Seclusion Record dated 05/13/25, nursing staff documented that the patient assaulted a peer and a staff member. The patient was angry and volatile, with a labile mood. Nursing staff documented that the patient was an immediate risk to others. iii. On the Seclusion Record dated 05/13/25, nursing staff documented that due to immediate danger, less restrictive measures could not be implemented prior to the intervention. Nursing staff documented that during the restrictive intervention, staff attempted the following less restrictive alternatives: active listening and meeting patient’s needs. However, nursing staff also documented that due to the immediate danger, less restrictive measures were not implemented during the intervention. iv. The patient was released from seclusion on 05/14/25 at 9:55 AM. After the patient’s release, she was observed walking around the ward, exhibiting social, labile, and manic behaviors. d. The Investigators’ review of the seclusion and restraint incidents that occurred on 04/23/25 at 12:04 PM, 05/07/25 at 3:00 PM, and 05/13/25 at 8:50 AM, found no evidence documenting the need for implementing seclusion and/or restraint. The hospital staff documented that the patient was cursing, aggressive, not able to plan for safety, however, staff failed to document evidence of behaviors where the patient was presented as an immediate/imminent danger to herself or others. 5. On 07/23/25, the Investigator reviewed the video provided by the hospital for the seclusion and restraint incident on 05/13/25 for Patient #5. The Investigator reviewed 2 videos, from 2 different cameras, providing a more comprehensive view of the event leading up to the patients’ seclusion. The videos showed the hospital’s shared dining room for ward 1North2. Both videos were approximately 10 minutes in length and did not contain audio, only video. There was no time stamp on the videos provided by the hospital. The review showed the following: a. 01(minutes):05(seconds) Patient #5 enters the dining room, walks to the cafeteria staff window and appears to be speaking with the staff. The patient then walks over to a table and sits down, facing the cafeteria window. b. 01:30 A staff member walks towards the patient with a meal tray. The patient swats the tray out of the staff members’ hand, and the tray and its contents land on the floor. The patient appears to be talking to staff and pointing to the food on the floor. c. 01:32 The patient walks away and leaves the dining room. As the patient is leaving the dining room, she is seen swatting a staff member who is standing in the doorway with the sleeve of her sweatshirt that is draped around her shoulders. The patient appears to be speaking to staff, and the staff is pointing down the hallway, appearing to be redirecting the patient. d. 03:00 The patient enters the dining room and walks past a staff member with a clipboard. The patient walks behind the staff members standing near the garbage can in the back of the dining room. e. 3:40 The patient appears to slip and fall on the floor. 2 staff members are standing above the patient on the floor and appear to be talking to her and pointing. Another patient appears and extends a hand to help Patient #5 up. A second patient comes to help and appears to be talking to Patient #5. One of the staff members helps the patient on to her feet. Two staff members then flank both sides of the patient and lead her out of the dining room. One of the staff members motions to a 3rd staff member to follow them down the hallway with the patient. The 3rd staff member follows Patient #5 and the other 2 staff members down the hallway. The angles of the video cameras did not allow for any additional viewing of the incident. f. 04:35 Staff are observed to be cleaning up something on the floor by the garbage can where the patient slipped and fell. The Investigator’s review of the video for the events leading to the seclusion and restraint incident on 05/13/25 found significant incongruencies between the provider and nursing staff’s documentation in the medical record and the video observations. The Investigator found no evidence that the patient assaulted a peer or staff member. There was no evidence that the patient presented as an immediate risk to self or others. Patient #8 6. The Investigator reviewed the medical record for Patient #8 who was admitted on 03/14/24. The review showed the following: a. On 03/27/24 at 12:25 AM, Patient #8 was placed in seclusion. i. On the Seclusion/Restraint Treatment Order dated 03/27/24, the provider documented that the reason for the intervention was due to the patient throwing their shoes and posturing towards staff. The patient attempted to hit the staff performing the 1:1 observation. ii. On the Seclusion Record dated 03/27/24, nursing staff documented the patient was restless and agitated. The patient attempted to hit and kick staff and threw her shoes at staff. The patient refused to be redirected. iii. On the Seclusion Record dated 03/27/24, nursing staff documented that prior to the intervention, staff attempted the following less restrictive alternatives: diversional activity, meeting patient’s needs, offering quiet space, and redirection. Staff documented that during the intervention, staff attempted to provide active listening, 1:1 with staff of choice, and meet the patient’s needs, however, staff checked the box noting “due to immediate danger, less restrictive measures could not be implemented during the intervention.” iv. The patient was released from seclusion on 03/27/24 at 3:00 AM. After the patient’s release, she was observed sleeping in her room. b. The Investigators’ review of the seclusion and restraint incident that occurred on 03/27/24 at 12:25 AM found no evidence documenting the need for implementing seclusion and/or restraint. The hospital staff documented that the patient was restless, agitated, and attempted to throw shoes and hit and kick staff, however, staff failed to document evidence of behaviors where the patient was presented as an immediate/imminent danger to himself or others. 7. On 07/09/25 at 1:15 PM, during an interview with the Investigator, the Chief Quality Officer (Staff #1) stated that the Quality Council has a peer review process for reviewing seclusion and restraint events to ensure that all elements in the documentation match. During incidents when patients’ behavior escalates, restraint should be the last resort. The hospital is using more seclusion, rather than placing patients in restraint. Staff #1 stated that the documentation found in the medical records should be congruent with the reported incident or any video review. Staff #1 stated that if an investigation is needed after a seclusion and restraint incident, there are several options for further investigation. The incident may be referred to the Allegations of Abuse (AOA) committee, the Ombudsmen, or the peer review committee for the Medical Executive Committee (MEC) for further review. 8. 07/10/25 at 8:40 AM, during an interview with the Investigator, Staff #1 stated that the hospital’s Zero Harm Group, created to ensure patient safety, reviews incidents of seclusion and restraint. The committee will review the medical record and review the video of incidents to ensure understanding of the complete picture. They will often recommend a more consistent process if they notice trends or gaps in practice. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 43948 . Based on interview, record review, and review of the hospital’s policies and procedures, the hospital failed to ensure that renewal orders for seclusion and/or restraint were authenticated by the physician/provider within the specified time limits for 7 of 8 records reviewed (Patients #1, #2, #3, #4, #5, #7, and #8). Failure to ensure that hospital staff follows the hospital’s established policies and procedures for the renewal of seclusion and restraint orders places the patient at risk for physical and psychological harm, loss of dignity, and violation of patient rights. Findings included: 1. Document review of the hospital’s policy titled, “BHA Seclusion and Restraint,” policy number BHA 10.34, approval date 08/13/24, showed that the orders for the use of seclusion and/or restraint for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient or staff will be renewed within 4 hours for adults 18 years of age or older. Facility procedures will guide how orders must be relayed and documented. A review of the hospital document titled, “Eastern State Hospital (ESH) Medical Staff Rules and Regulations,” no document number, not dated, showed that the standard for the authentication of non-medication verbal/telephone orders is within 48 hours. Staff are directed to flag the chart for the prescribing practitioner. Any verbal/telephone order must be dated, timed, and authenticated by the prescribing practitioner, or another practitioner who is responsible for the care of the patient, within 48 hours. Patient #1 2. The Investigator reviewed the medical record for Patient #1 who was admitted on 03/27/25. The review showed the following: a. Hospital staff documented 7 seclusion and manual restraint incidents for Patient #1: 03/27/25, two incidents on 03/30/25, 03/31/25, 04/02/25, 05/03/25, and 05/04/25. b. On 03/30/25 at 11:00 AM, Patient #1 was placed in seclusion after staff documented that the patient threatened to stab a staff member and punched a staff member in the chest. The patient was released from seclusion on 03/31/25 at 9:45 AM. A review of the seclusion order and renewal orders found that the provider failed to authenticate 5 of 5 four-hour renewal orders: 03/30/25 at 3:00 PM, 03/30/25 at 7:00 PM, 03/30/25 at 11:00 PM, 03/31/25 at 3:00 AM, and 03/31/25 at 7:00 AM. c. On 04/02/25 at 12:14 PM, the patient was placed in seclusion after he attempted to hit a staff member. The patient was released from seclusion on 04/05/25 at 10:00 AM. The provider failed to authenticate 7 of 17 four-hour renewal orders: 04/03/25 at 8:00 PM, 04/04/25 at 12:00 AM, 04/04/25 at 4:00 AM, 04/04/25 at 8:00 PM, 04/05/25 at 12:00 AM, 04/05/25 at 4:00 AM, and 04/05/25 at 8:00 PM. Patient #2 3. The Investigator reviewed the medical record for Patient #2 who was admitted on 04/15/25. The review showed the following: a. Hospital staff documented 6 seclusion and manual restraint incidents for Patient #2: 04/23/25, 04/28/25, 05/27/25, 06/06/25, 06/14/25, and 06/24/25. b. On 04/28/25 at 5:46 PM, Patient #2 was placed in seclusion after staff documented that the patient assaulted a staff member without provocation. The medical record did not contain documentation of the date and time that the patient was released from seclusion. On the Seclusion Record dated 05/01/25 at 12:00 AM, nursing staff documented that the patient remained unsafe to others. However, the last Seclusion/Restraint Treatment Order renewal order was dated 05/02/25 at 8:00 AM and signed by the provider. Further review of the seclusion and renewal orders found that the provider failed to authenticate 1 of 22 four-hour renewal orders: 05/01/25 at 4:00 PM. Patient #3 4. The Investigator reviewed the medical record for Patient #3 who was admitted on 05/28/25. The review showed the following: a. Hospital staff documented 2 seclusion and restraint incidents for Patient #3: 05/28/25 and 06/17/25. b. On 05/28/25 at 10:48 PM, Patient #3 was placed in seclusion and 5-point restraints after punching and head-butting a staff member. The patient was released from restraints on 05/28/25 at 11:41 PM and from seclusion on 05/29/25 at 8:06 AM. A review of the seclusion order and renewal orders found that the provider failed to authenticate 3 of 3 four-hour renewal orders: 05/28/25 at 11:41 PM, 05/29/25 at 3:00 AM, and 05/29/25 at 7:00 AM. Patient #4 5. The Investigator reviewed the medical record for Patient #4 who was admitted on 05/15/25. The review showed that the patient was placed directly into seclusion upon his admission to the hospital at 12:02 PM. The patient was released from seclusion on 05/25/25 at 9:15 AM. A review of the seclusion order and renewal orders found that the provider failed to authenticate a four-hour renewal order on 05/18/25 at 2:00 PM. Patient #5 6. The Investigator reviewed the medical record for Patient #5 who was admitted on 04/23/25. The review showed the following: a. Hospital staff documented 3 seclusion and manual restraint incidents for Patient #5: 04/23/25, 05/07/25, and 05/13/25. b. On 04/23/25 at 12:04 PM, Patient #5 was placed in seclusion. Staff documented that the patient was cursing, spitting and slapping staff. The patient was released from seclusion on 05/07/25 at 1:10 PM. A review of the seclusion order and renewal orders found that the provider failed to authenticate 24 of 84 four-hour renewal orders: 04/27/25 at 4:00 PM, 04/27/25 at 8:00 PM, 04/28/25 at 12:00 AM, 04/28/25 at 4:00 AM, 04/28/25 at 8:00 AM, 04/29/25 at 8:00 PM, 04/30/25 at 12:00 AM, 04/30/25 at 4:00 AM, 05/01/25 at 9:00 PM, 05/02/25 at 1:00 AM, 05/02/25 at 5:00 AM, 05/02/25 at 9:00 PM, 05/03/25 at 1:00 AM, 05/03/25 at 5:00 AM, 05/04/24 at 5:00 PM, 05/04/25 at 9:00 PM, 05/05/25 at 1:00 AM, 05/05/25 at 5:00 AM, 05/05/25 at 9:00 PM, 05/06/25 at 1:00 AM, 05/06/25 at 5:00 AM, 05/06/25 at 9:00 PM, 05/07/25 at 1:00 AM, and 05/07/25 at 5:00 AM. c. On 05/07/25 at 3:00 PM, the patient was placed in seclusion. Staff documented that the patient was unable to safety plan and had been aggressive and assaultive previously. The patient was released from seclusion on 05/09/25 at 1:13 PM. The provider failed to authenticate 7 of 12 four-hour renewal orders: 05/07/25 at 7:00 PM, 05/07/25 at 11:00 PM, 05/08/25 at 2:00 AM, 05/08/25 at 6:00 AM, 05/08/25 at 9:00 PM, 05/09/25 at 1:00 AM, and 05/09/25 at 5:00 AM. d. On 05/13/25 at 8:50 AM, the patient was placed in seclusion. Staff documented that the patient assaulted a peer and staff member. The patient was released from seclusion on 05/14/25 at 9:55 AM. The provider failed to authenticate the initial order on 05/13/25 at 8:50 AM and 3 of 5 four-hour renewal orders: 05/14/25 at 12:00 AM, 05/14/25 at 4:00 AM, and 05/14/25 at 8:00 AM. Patient #7 7. The Investigator reviewed the medical record for Patient #7 who was admitted on 03/17/25. The review showed the following: a. Hospital staff documented 4 seclusion and restraint incidents for Patient #7: 04/19/25, 04/26/25, 05/02/25, and 05/15/25. b. On 05/02/25 at 12:08 PM, Patient #7 was placed in seclusion. Staff documented that the patient was posturing and attempting to assault a peer. The patient was released from seclusion on 05/03/25 at 8:00 AM. A review of the seclusion order and renewal orders found that the provider failed to authenticate 4 of 4 four-hour renewal orders within 48 hours: 05/02/25 at 4:00 PM, 05/02/25 at 8:00 PM, 05/03/25 at 12:00 AM, and 05/03/25 at 04:00 AM. The provider authenticated each of the renewal orders on 05/12/25 at 8:00 AM. c. On 05/15/25 at 3:25 PM, Patient #7 was placed in seclusion. Staff documented that the patient was verbally and physically aggressive towards peers and staff. The patient was released from seclusion on 05/15/25 at 9:35 PM. A review of the seclusion renewal orders found that the provider failed to authenticate 1 of 1 renewal orders: 05/15/25 at 7:00 PM. Patient #8 8. The Investigator reviewed the medical record for Patient #8 who was admitted on 03/14/24. The review showed the following: a. Hospital staff documented 4 seclusion and restraint incidents for Patient #8: 03/19/24, 03/27/24, 04/05/24, and 04/26/24. b. On 04/05/24 at 8:02 PM, Patient #7 was placed in seclusion. Staff documented that the patient assaulted a peer without provocation. The patient was released from seclusion on 04/06/24 at 2:00 AM. A review of the seclusion order and renewal orders found that the provider failed to authenticate 1 of 1 renewal orders: 04/05/24 at 11:45 PM. 9. On 07/23/25 at 3:30 PM, during an interview with the Investigator, the Chief Quality Officer (Staff #1) and the Chief Nursing Officer (Staff #3) verified that the provider’s failed to consistently authenticate the required four-hour renewal orders within 48 hours. Staff #3 reported that they would be following up with the Chief Medical Officer to speak with the providers immediately. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (ii) After 24 hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, 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 must see and assess the patient. This Standard is not met as evidenced by: 43948 . Based on interviews, record review, and review of the hospital’s policies and procedures, the hospital failed to ensure that the physician or nurse practitioner reevaluated patients in seclusion and/or restraint every 24 hours prior to writing a new order for seclusion and/or restraint for 2 of 8 records reviewed (Patients #4 and #5). Failure to ensure that hospital staff reevaluate patients in seclusion and/or restraint every 24 hours and document the patient’s behaviors which required the continuation of seclusion and/or restraint places the patient at risk for the patient being in restraint/seclusion longer than needed, physical and psychological harm, and violation of patient rights. Findings included: 1. Document review of the hospital’s policy titled, “BHA Seclusion and Restraint,” policy number BHA 10-34, approval date 08/13/24, showed the following: a. Orders for the use of seclusion and/or restraint for the management of violent or self-destructive behavior that jeopardize the physical safety of the patient, staff, and/or others will be renewed within the following time limits: 4 hours for adults 18 years of age or older. Facility procedures will guide how orders must be relayed and documented. b. Prior to the 24th hour, a physician or nurse practitioner must see and evaluate the patient before writing a new order for restraint and/or seclusion. The physician or nurse practitioner will review the patient’s existing medication orders and will assess the need for modifying such orders during the period of seclusion or restraint. Documentation of this review will be in the medical record. Document review of the hospital’s document titled, “Seclusion/Restraint Audit,” no document number, dated 05/01/24, showed that per PC.03.05.05.EP 5, every 24 hours a physician primarily responsible for the patient’s ongoing care sees and evaluates the patient before writing a new order for seclusion and restraint. Patient #4 2. The Investigator reviewed the medical record for Patient #4 who was admitted on 05/15/25. The review showed the following: a. On 05/15/25 at 12:02 PM, Patient #4 was placed directly into seclusion upon his admission to the hospital. The patient was released from seclusion on 05/25/25 at 9:15 AM. b. On the Seclusion/Restraint Treatment Order dated 05/16/25 at 8:50 AM, the provider documented the face-to-face assessment, noting the patient’s physical condition, reaction to the intervention, and the justification for continuing seclusion. On the Seclusion/Restraint Treatment Order dated 05/17/25 at 10:00 AM, the provider documented conducting the face-to-face assessment for the renewal of the seclusion order, over 24 hours after the previous order (1 hour 10 minutes). c. On the Seclusion/Restraint Treatment Order dated 05/19/25 at 8:50 AM, the provider documented the face-to-face assessment, noting the patient’s physical condition, reaction to the intervention, and the justification for continuing seclusion. On the Seclusion/Restraint Treatment Order dated 05/20/25 at 10:00 AM, the provider documented conducting the face-to-face assessment for the renewal of the seclusion order, over 24 hours after the previous order (1 hour 10 minutes). d. On the Seclusion/Restraint Treatment Order dated 05/21/25 at 8:15 AM, the provider documented the face-to-face assessment, noting the patient’s physical condition, reaction to the intervention, and the justification for continuing seclusion. On the Seclusion/Restraint Treatment Order dated 05/22/25 at 10:00 AM, the provider documented conducting the face-to-face assessment for the renewal of the seclusion order, over 24 hours after the previous order (1 hour 45 minutes). Patient #5 3. The Investigator reviewed the medical record for Patient #5 who was admitted on 04/23/25. The review showed the following: a. On 04/23/25 at 12:04 PM, Patient #5 was placed in seclusion. Staff documented that the patient was cursing, spitting and slapping staff. The patient was released from seclusion on 05/07/25 at 1:10 PM. On 05/05/25 at 12:00 PM, the provider documented the face-to face-assessment. On 05/07/25, no time noted, the provider documented the face-to-face assessment. The review of the seclusion and restraint incident showed that the provider failed to complete and document the 24-hour face-to-face assessment on 05/06/25. b. On 05/13/25 at 8:50 AM, the patient was placed in seclusion. Staff documented that the patient assaulted a peer and staff member. The patient was released from seclusion on 05/14/25 at 9:55 AM. The review of the incident showed the following: i. On the Seclusion Record, staff documented that the patient was placed into seclusion on 05/13/25 at 8:50 AM. On the Seclusion/Restraint Treatment Order dated 05/13/25, the provider documented that the one-hour physician face-to-face assessment was conducted at 12:45 PM, 3 hours and 55 minutes after the patient was placed into seclusion. ii. The review found no evidence that the provider conducted a second face to face assessment prior to the patient’s release from seclusion on 05/14/25 at 9:55 AM, over 24 hours after they were placed into seclusion, as directed by hospital policy. 4. On 07/09/25 at 1:15 PM, during an interview with the Investigator, the Chief Quality Officer (Staff #1) stated that there are registered nurses who assist the Quality Council to audit the seclusion and restraint documents for accuracy, completion, and congruency. Staff #1 state that they do not review the provider’s documentation. 5. On 07/23/25 at 3:30 PM, during an interview with the Investigator, Staff #1 and the Chief Nursing Officer (CNO) (Staff #3) verified that the provider’s failed to consistently perform the 24-hour face-to-face evaluation required for patients who are in seclusion and restraint for over 24 hours. The CNO reported that they would be following up with the Chief Medical Officer to speak with the providers immediately. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 43948 . Based on observations, interviews, record review, and review of the hospital’s policies and procedures, the hospital failed to ensure that patients were removed from seclusion and/or restraints at the earliest possible time for 7 of 8 records reviewed. (Patients #1, #2, #3, #4, #5, #7, and #8). Failure to remove patients from seclusion and/or restraints at the earliest possible time places the patient at risk for physical and psychological harm, loss of dignity, and violation of patient rights. Findings included: 1. Document review of the hospital’s policy titled, “BHA Seclusion and Restraint,” policy number BHA 10-34, approval date 08/13/24, showed the following: a. All patients have the right to be free from restraint and seclusion, of any form, imposed as a means to coercion, discipline, convenience, or retaliation by staff. b. Seclusion or restraint is only used in situations where the patient presents an immediate/imminent physical danger to themselves and/or others and lesser restrictive interventions are not effective in remedying the danger. c. Seclusion or restraint will be discontinued as soon as the imminent/immediate risk to self or others is no longer present, or the patient’s need can be addressed using less restrictive measures regardless of the schedule expiration of the order. d. When the clinical assessment indicates the patient will no longer pose a safety threat, they will be released immediately. A licensed provider or registered nurse (RN) has the authority to determine when to release the patient from seclusion and/or restraint prior to the expiration of the order. A review of the hospital’s training document titled, “DSHS BHA Eastern State Hospital (ESH) Regulatory Standards for Seclusion/Restraint 2025,” no document number, not dated, showed the following: a. Seclusion may only be used for the management of violent or self-destructive behavior. b. Restraint may be physical (any method to restrict movement) or chemical (a drug or medication used to manage a person’s behavior or restrict their freedom of movement). c. Seclusion and/or restraint may be used when a presents as an immediate danger by an actual physical act of violence toward self or others, or actual destruction of property. d. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. e. Examples of what immediate danger is not: i. A patient punches a wall and goes to their room. ii. A patient postures at another patient and goes to their room. iii. A patient is cursing aggressively, threatening a peer or staff member, with no physical act of violence. iv. A patient throws food and/or water and walks to their room. f. All patients deserve release from seclusion and/or restraint as soon as it is safe to do so. This means when the immediate threat of danger is over and the patient can integrate back into the milieu safely. Patient #1 2. The Investigator reviewed the medical record for Patient #1 who was admitted on 03/27/25. The review showed the following: a. Hospital staff documented 7 seclusion and manual restraint incidents for Patient #1: 03/27/25, two incidents on 03/30/25, 03/31/25, 04/02/25, 05/03/25, and 05/04/25. b. On 03/27/25 at 1:40 PM, Patient #1 was placed in seclusion and given emergency medications (Geodon and Ativan) upon arrival at the hospital after the patient attempted to grab at staff (while in restraints), accusing them of molesting him. Once the patient was placed in seclusion, the documentation on the hourly registered nurse (RN) assessments included observations that the patient was restless, irritable, pacing, responding to internal stimuli, ignoring staff, and aggressive with responses, and continued in seclusion for the following periods: i. On 03/27/25 at 3:00 PM, staff documented that the patient remained unpredictable, however failed to document what behaviors were considered unpredictable. ii. On 03/27/25 at 6:00 PM, 7:00 PM, and 8:00 PM, nursing assessments showed that the patient was unpredictable and unsafe with an increased risk of dangerous acts. The nursing staff documented their observations of the patient’s behaviors to include restlessness, pointing at the camera, responding to internal stimuli, and placing the blanket over his head. iii. From 03/27/25 at 9:00 PM and 03/28/25 at 6:00 AM, nursing staff documented that the patient ignored assessment questions and was actively pacing, walking around the room, pre-occupied, staring at the ceiling, was restless, lying on the mat, and waving his hands in the air. Nursing staff documented that the patient was highly assaultive and remained an imminent risk to others, however the staff did not document evidence of assaultive behaviors. iv. The patient was released from seclusion on 03/28/25 at 7:00 AM. At 7:30 AM, staff documented that the patient patient was sleeping in his room. v. The Investigator’s review of the seclusion records and hourly RN assessments for this incident found that the staff failed to document observations of behaviors that demonstrated that the patient was an imminent risk to himself or others, which would require continued seclusion. c. On 03/30/25 at 6:10 AM, Patient #1 was placed in seclusion after threatening others and was uncooperative and not redirectable. The documentation on the hourly RN assessments included observations that the patient was pacing, responding to internal stimuli, ignoring staff, undressing, and making delusional statements. During the period of seclusion, nursing documentation showed: i.On 03/30/25 at 7:00 AM, staff documented that the patient exhibited unsafe behavior and was unpredictable, however, staff failed to document what behaviors were considered unpredictable other than restless, disorganized, and confused. ii. The patient was released from seclusion on 03/30/25 at 8:00 AM. Staff documented that the patient was able to follow directions, take medication, and put his clothes back on. At 8:30 AM, staff documented that the patient was calmly pacing on the ward and mumbling. iii. The Investigator’s review of the Seclusion Records and hourly RN assessments for this incident found that staff failed to document observations that demonstrated that the patient was an imminent risk to himself or others, which would require continued seclusion. d. On 03/30/25 at 11:00 AM, Patient #1 was placed back into seclusion after threatening staff and punching staff in the chest. The documentation on the hourly RN assessments included observations that the patient was pacing, responding to internal stimuli, ignoring staff, crawling on the floor, screaming, and unable to follow directions from staff. The patient was released from seclusion on 03/31/25 at 9:45 AM. Staff documented that the patient was disorganized, but calm and cooperative. At 10:15 AM, staff documented that the patient was watching TV in the milieu. e. On 03/31/25 at 9:03 PM, Patient #1 was placed back into seclusion after pushing through staff, becoming intrusive, and not being redirectable. The documentation on the hourly RN assessments included observations that the patient was pacing, responding to internal stimuli, agitated, crawling on the floor, undressing, and unable to follow directions from staff. Patient #1 remained in seclusion until 04/02/25 at 11:10 AM. Staff documented that the patient was disorganized, but calm and cooperative. At 11:40 AM, staff documented that the patient was watching TV in the milieu. f. On 04/02/25 at 12:14 PM, Patient #1 was placed into seclusion after attempting to hit a staff member. The documentation on the hourly RN assessments included observations that the patient was pacing, responding to internal stimuli, manic, appeared to be sleeping/resting, tense, and not responding to staff. Patient #1 remained in seclusion until 04/05/25 at 10:00 AM. At the time of the patient’s release from seclusion, staff documented that the patient was sleeping. g. The Investigator’s review of the seclusion records and hourly RN assessments for seclusion and restraint incidents on 03/30/25, 03/31/25, and 04/02/25, found that staff failed to document observations of behaviors that demonstrated that the patient was an imminent risk to himself or others, which would require continued seclusion. h. On 05/03/25 at 6:05 PM, Patient #1 was placed into seclusion. Staff documented that the patient assaulted a staff member without provocation. The documentation on the hourly RN assessments included observations that the patient was pacing aggressively, responding to internal stimuli, banging on the wall, refusing to eat/drink, and constantly pacing in circles. At 9:25 PM, seclusion was discontinued. At the time of the patient’s release from seclusion, staff documented that the patient was calm, following directions and went to his room. i. On 07/15/25, the Investigator reviewed the video provided by the hospital for the seclusion and restraint incident on 05/03/25 for Patient #1 and found incongruencies between the staff’s documentation in the medical records and the observation of the incident captured on the videos: i. The Investigator reviewed a video titled Nurse Station. The video was 2 minutes in length, did not contain audio, and showed the incident that led to the seclusion. The beginning of the video showed Patient #1 pacing in the hallway. At 38 seconds, the patient moved towards a male staff member with his hands extended. The male staff member extended his hand out towards the patient and backs the patient up against the wall. 3 other staff members assist in containing the patient and walk him towards the seclusion room.The video showed no evidence of Patient #1 striking or hitting any staff members. ii. The Investigator also reviewed 2 additional videos, from 2 different cameras angles, providing a comprehensive view of the seclusion room. Both videos were 60 minutes in length, did not contain audio, and showed the first 60 minutes of the patient’s seclusion. At 13 seconds, two staff members were observed positioned on opposite sides of Patient #1 holding him by the arms and leading him into the seclusion room. The observation showed one staff member place his foot in from of Patient #1’s feet, causing the patient to trip and fall to the floor. At 21 seconds, the staff exit the seclusion room, closing the door behind them. The review showed the patient pacing in the seclusion room for the remaining time. At 19 minutes and 32 seconds, the patient paused pacing to remove his shoes, then continued pacing. At 21 minutes and 39 seconds, the patient paused again to put his shoes back on, then resumed pacing around the seclusion room in a circular pattern. The review of the videos failed to find evidence of the patient punching the wall, posturing at the camera, waving his arms around, or screaming and the nursing staff, as documented by nursing staff on the seclusion record dated 05/03/25. The video review for the first 60 minutes of the patient’s seclusion on 05/03/25, initiated at 6:05 PM, showed that the patient did not appear to be at imminent risk to himself or others. j. On 05/04/25 at 7:10 AM, Patient #1 was placed into seclusion after assaulting a staff member. The documentation on the hourly RN assessments included observations that the patient was pacing, responding to internal stimuli, making delusional statements, slapping his hands on the wall, pacing, defiant to staff, requesting a blanket and resting on mattress, refusing fluids and not responding to staff. The patient was released from seclusion on 05/07/25 at 9:59 AM. At the time of the patient’s release from seclusion, staff documented that the patient was lying in bed. k. The Investigator’s review of the seclusion records and hourly RN assessments for seclusion and restraint incidents on 05/04/25 found that staff failed to document observations of behaviors that demonstrated that the patient was an imminent risk to himself or others, which would require continued seclusion. Patient #2 3. A review of medical records showed that Patient #2 was admitted on 04/15/25 and had 6 documented seclusion and manual restraint incidents since admission: 04/23/25, 04/28/25, 05/27/25, 06/06/25, 06/14/25, and 06/24/25. a. On 04/23/25 at 2:20 PM, the patient was placed into seclusion after he assaulted a peer without provocation. The patient was released from seclusion on 04/24/25 at 10:15 AM. Review of the seclusion records hourly RN assessments showed that for 18 of 20 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. b. On 04/28/25 at 5:46 PM, the patient was placed into seclusion after he assaulted a staff member without provocation. Staff failed to document the date and time that the patient was released from seclusion. Review of the seclusion records dated 04/28/25 at 5:46 PM to midnight on 05/01/25 showed that for 44 of 48 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. c. On 05/27/25 at 5:45 PM, the patient was placed into seclusion after he assaulted 2 peers without provocation The patient was released from seclusion on 05/31/25 at 10:00 AM. Review of the seclusion records hourly RN assessments showed that for 77 of 78 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. d. On 06/14/25 at 7:45 PM, the patient was placed into seclusion after he threatened to assault a peer. The patient was released from seclusion on 06/15/25 at 3:00 PM. Review of the seclusion records hourly RN assessments showed that for 20 of 20 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. e. On 06/24/25 at 6:18 AM, the patient was placed into seclusion after grabbing a staff’s glasses. The patient was released from seclusion on 06/24/25 at 10:40 AM. Review of the seclusion records hourly RN assessments showed that for 4 of 4 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. Patient #3 4. A review of medical recods showed Patient #3 was admitted on 05/28/25. Hospital staff documented 2 seclusion and restraint incidents for Patient #3: 05/28/25 and 06/17/25. a. On 05/28/25 at 10:48 PM, the patient was placed into mechanical 5-point restraints and seclusion after he attempted to assault a staff member. The patient was released from restraints on 05/28/25 at 11:41 PM and was released from seclusion on 05/29/25 at 8:06 AM. Review of the seclusion records hourly RN assessments showed that for 10 of 14 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. b. On 06/17/25 at 7:03 PM, the patient was placed into seclusion after assaulting a peer without provocation. The patient was released from seclusion on 06/23/25 at 9:00 AM. Review of the seclusion records hourly RN assessments showed that for 82 of 90 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. Patient #4 5. A review of the medical record showed Patient #4 was admitted on 05/15/25. Hospital staff documented 1 seclusion and restraint incident for Patient #4 on 05/15/25. On 05/15/25 at 12:02 PM, the patient was placed was placed directly into seclusion upon his admission to the hospital due to threatening/aggressive behavior during transport by law enforcement. The patient was released from seclusion on 05/25/25 at 9:15 AM. Review of the seclusion records hourly RN assessments showed that for 227 of 239 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. Patient #5 6. A review of the medical record showed Patient #5 was admitted on 04/23/25. Hospital staff documented 3 seclusion and manual restraint incidents for Patient #5: 04/23/25, 05/07/25, and 05/13/25. a. On 04/23/25 at 12:04 PM, the patient was placed into seclusion after staff documented that the patient was spitting, hitting, and kicking staff. The patient was released from seclusion on 05/07/25 at 1:10 PM. Review of the seclusion secord RN assessments showed that for 338 of 338 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. b. On 05/07/25 at 3:00 PM, the patient was placed back into seclusion after staff documented that the patient was unable to safety plan. The patient was released from seclusion on 05/09/25 at 1:13 PM. Review of the seclusion records RN assessments showed that for 47 of 47 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. c. On 05/13/25 at 8:50 AM, the patient was placed into seclusion after staff documented that the patient was assaultive towards peers and staff. The patient was released from seclusion on 05/14/25 at 9:55 AM. The review of the Seclusion Records RN assessments showed that for 25 of 25 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. d. On 07/23/25 the Investigator reviewed 3 videos provided by the hospital for the seclusion and restraint incident on 05/13/25 for Patient #5. Two of the videos showed seclusion room door on 1 North 3 and began with the patient’s placement in the seclusion room. One video was 1 hour and 40 minutes in length and the other was 56 minutes in length. The third video show video from the opposite angle, facing away from the seclusion room door and was 2 hours and 35 minutes long. The 3 videos reviewed showed no evidence that Patient #5 exhibited an imminent risk to herself or others, however, the patient remained in seclusion for over 24 hours. Patient #7 7. A medical record review showed Patient #7 was admitted on 03/17/25. Hospital staff documented 4 seclusion and manual restraint incidents for Patient #7: 04/19/25, 04/26/25, 05/02/25, and 05/15/25. a. On 04/26/25 at 1:00 PM, the patient was placed into seclusion after staff documented that the patient was aggressive, agitated, and threatening. The patient was released from seclusion on 04/27/25 at 12:00 PM. The review of the seclusion records RN assessments showed that for 22 of 25 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. b. On 05/02/25 at 12:08 PM, the patient was placed into seclusion after posturing and attempting to assault a peer. The patient was released from seclusion on 05/03/25 at 8:00 AM. The review of the seclusion records RN assessments showed that for 20 of 20 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. c. On 05/15/25 at 3:25 PM, the patient was placed into seclusion after staff documented that the patient was verbally and physically aggressive with staff. The patient was released from seclusion on 05/15/25 at 9:35 PM. The review of the seclusion records RN assessments showed that for 7 of 7 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. Patient #8 8. A medical record review showed Patient #8 was admitted on 03/14/24. Hospital staff documented 4 seclusion and manual restraint incidents for Patient #8: 03/19/24, 03/27/24, 04/05/24, and 04/26/24. a. On 03/27/24 at 12:25 AM, the patient was placed into seclusion after she threw her shoes at staff and attempted to hit a staff member. The patient was released from seclusion on 03/27/24 at 3:00 AM. Review of the Seclusion Records RN assessments showed that for 2 of 3 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. b. On 04/05/24 at 8:02 PM, the patient was placed into seclusion after she assaulted a peer without provocation. The patient was released from seclusion on 04/06/24 at 2:00 AM. Review of the seclusion records RN assessments showed that for 5 of 6 hourly assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. c. On 04/26/24 at 11:25 AM, the patient was placed into 6-point restraints and seclusion after she assaulted a staff member. The patient was released from restraints and seclusion on 04/26/24 at 12:30 PM. Review of the seclusion records RN assessments showed that for 3 of the 4 (15 minute assessments - required for patients in restraints) assessments, nursing staff failed to document observations of behaviors that demonstrated that the patient was at an imminent risk to himself or others requiring continued seclusion. 9. On 07/09/25 at 1:15 PM, Investigator interviewed the Chief of Quality (Staff #1) and the Chief Nursing Officer (Staff #3) about the hospital’s process for the review of seclusion and restraint incidents. Staff #3 stated that the nurse managers (RN4) do a review of all the seclusion and restraint documentation for every incident to ensure that all patients are released from seclusion at the earliest possible time. When asked by the Investigator if the videos for incidents were available for the nurse managers to review during audits to compare with the documentation in the medical record, Staff #3 stated that nursing did not typically have access to the videos. Staff #3 stated that the Ombudsman has access to the videos for some incidents and reviews and compares what is found in the video to the documentation found in the medical record. Staff #1 stated that the Ombudsman will notify the Chief Executive Officer and the Deputy Chief Executive Officer if there is a concerning incident and share the video and summary of the incident with the leadership. 10. On 07/14/25 at 2:00 PM during an interview with the Investigator, the Ombudsman (Staff #9) stated that even with the audits and review processes conducted, the hospital is not checking to ensure that the documentation lines up with the videos. During reviews, Staff #9 found that staff were documenting assessments that did not reflect the patient’s behaviors as observed on the video review. Staff #9 stated that the RNs are documenting that the patients are not safe to be released from seclusion and are an imminent danger to self or others, but the video reviews of the incidents do not support the need for continued seclusion. Staff #9 stated that when concerning incidents are discovered, a summary of the incident is forwarded to the hospital leaders for review. This summary report also included relevant documents from the medical record and the video of the incident. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(iv) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (iv) The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia). This Standard is not met as evidenced by: 43948 . Based on observation, interview, record review, and review of the hospital’s policies and procedures, the hospital failed to provide comprehensive staff training on the use of manual and mechanical restraints, restraint equipment, and techniques for the safe transport of patients, when indicated, as demonstrated by 3 of 4 medical records reviewed (Patients #1, #2, and #4). Failure to ensure that hospital staff received comprehensive training that guides their response to behavioral/psychiatric emergencies requiring the use of restraint and seclusion, places the patient at risk for serious harm or injury, and violates the patient’s right to receive care in a safe setting. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Patient Rights and Responsibilities,” policy number ESH 10.27, approval date 08/04/23, showed that the patient’s basic rights included: a. To be treated with dignity, courtesy, and respect. b. Safe care and a humane environment that provides protection from harm. c. To be free from all forms of abuse or harassment. Document Review of the hospital’s policy and procedure titled, “Code Gray,” policy number ESH 10.133, effective date 11/01/24, showed the following: a. Code Gray Definition - Staff response to an acute psychiatric or behavioral emergency. When a patient is escalating to the point when imminent risk of harm to others is apparent, and viable less restrictive alternatives (LRA) to help the patient exert control over their own behavior are not successful. Code Gray is an emergency alert call requesting additional clinical staff to respond to the location. b. The Code Gray Team is typically led by the Registered Nurse (RN) 3 or a designee. Responsibilities include assignment of tasks to team members, preparation of the seclusion room (if needed), ensure restraints or restraint beds are available, and manage other patients not involved in the crisis. Document Review of the hospital’s policy and procedure titled, “Seclusion and Restraint,” policy number BHA 10.34, approval date 08/13/24, showed the following: a. All staff who may be involved in seclusion or restraint procedures must review and be familiar with this policy. Staff authorized to participate in seclusion and restraint actions will receive training in de-escalation techniques. b. All staff who may potentially participate in a seclusion or restraint procedure will attend training during New Employee Orientation (NEO), and at least every 3 years thereafter. Document Review of the hospital’s policy and procedure titled, “ESH Interdisciplinary Protocol for Seclusion and Restraint,” no policy number, approval date 05/30/23, showed the following: a. Prone position definition - Lying face down. Outside of the exceptional clinical situation, use of mechanical restraint in the prone position is not permitted at ESH. b. Supine position definition - Lying face up. c. Types of restraints: i. Bed restraints are often referred to by point. For example, 1 point is waist belt to bed or chair, 2 point is wrist or ankle restraints, 3 point is two extremities (wrist or ankle) and waist belt, 4 point is four extremities, 5 point is four extremities and a waist belt, 6 point is four extremities, waist belt and chest belt, and 7 point is four extremities, waist, chest, and thigh belt. ii. Ambulatory restraints include ankle and/or wrist restraints. iii. Restraint chair consists of a specially designed chair which restrains the shoulder, waist, wrist, and ankle. The review of the hospital’s training curriculum titled, “Crisis Prevention Institute (CPI) Training,” showed that the training focused on non-violent crisis intervention, providing staff with de-escalation training solutions. In addition, the hospital provided the Investigator with talking points and attestations for the use of ambulatory restraints and the restraint chair. At the time of the investigation, the hospital had no other crisis intervention or behavioral/psychiatric emergency training. Patient #1 2. The Investigator reviewed the medical record for Patient #1, who was admitted on 01/24/25. The review showed the following: a. On a Progress Note dated 01/24/25 at 12:33 PM, nursing staff documented that the patient arrived on the ward escorted by 2 Spokane police officers. During the initial nursing assessment, the patient lunged at the admitting nurse, threating to kill her. The patient was taken directly to the seclusion room by law enforcement. b. On a Progress Noted dated 01/25/25 at 1:20 PM, nursing staff documented that the patient remained in seclusion. The patient reported that he did not feel safe being released from seclusion and felt that if he was released, he would assault others or be assaulted. c. On a Progress Note dated 01/25/25 at 9:22 PM, nursing staff documented that the patient was released from locked seclusion and placed on 1:1 observation monitoring and distant assaultive precautions (DAP) due to aggressive assaultive behavior. The patient chose to remain in the seclusion room with the door unlocked. d. On 01/26/25 at 10:51 PM, nursing staff documented that at 8:57 PM the patient exited the unlocked seclusion room, walked past the Forensic Care Associate (FCA) who was performing their 1:1 monitoring, and attacked another staff member who was in the hallway monitoring a different patient. The nursing staff documented that the patient was then placed in locked seclusion. 3. On 03/18/25 at 12:30 PM, the Investigator met with the Director of Security (Staff #4), to review Patient #1’s video footage from the incident on 01/26/25. The incident was recorded from 8:50 PM to 9:00 PM. The Investigator observed that at 8:56 PM, Patient #1 exited the unlocked seclusion room, walk behind the FCA staff, tasked with his 1:1 monitoring, and walking directly to another FCA staff member. Patient #1 began punching the staff member in the head repeatedly. The staff member moved toward the nursing station and entered the locked area. Patient #1 continued to assault the staff member, following them into the nursing station. The Investigator observed 6 staff members contain the patient on the ground in a prone position. The staff did not utilize mechanical restraints, the restraint chair, or the med sled during the incident. The staff members continued to manually restrain the patient, holding him on the ground for several seconds. The staff secured the patient’s extremities, turned the patient on his back, and 6 staff members dragged the patient by his feet down the hallway towards the seclusion room. The patient was placed in the seclusion room, staff backed out of the room, and the door was locked. Patient #2 4. The Investigator reviewed the medical record for Patient #2, who was admitted on 01/31/25. The review showed the following: a. On the Seclusion Record dated 02/02/25, staff documented that at 12:33 PM the patient assaulted a peer and two staff members without provocation. A Code Gray was called, and the patient was manually restrained, taken to the seclusion room and placed on locked seclusion. b. On a Code Gray Recording Form dated 02/03/25 at 4:45 AM, nursing staff documented that the patient remained in locked seclusion and requested to use the restroom which was in an alcove outside of the seclusion room. Prior to escorting the patient to the restroom, the nursing staff requested assistance from additional staff members due to the patient’s previous assaultive behavior. The seclusion room door was unlocked and opened. The patient immediately lunged at the staff and began punching wildly, hitting 3 female nurses in the head and face. A Code Gray was called at 3:45 AM for additional staff support. The patient was then contained. The patient went deadweight, and staff physically supported the patient while he was taken to a different seclusion room that had a private bathroom. The nursing staff documented that there was no observable injury to the patient. The patient did not respond to the provider when asked if he was hurt during the incident. c. On the Physician Progress Note dated 02/03/25, the physician documented that on 02/03/25 at approximately 3:30 AM, staff assisted the patient to the restroom. The patient attacked “at least three female staff, hitting them in the head and face, causing injuries.” 5. On 03/18/25 at 12:30 PM, the Investigator met with the Director of Security (Staff #4), to review Patient #2’s video footage from the incident on 02/03/25. The recording showed that the incident began at 3:40 AM. Six staff members responded to the patient’s request to use the restroom. Immediately after the seclusion room door was unlocked, Patient #2 quickly advanced towards a female staff member and began punching her in the head and face. The patient then continued to assault 2 additional female staff members, by punching and hitting them in the head and face. The Investigator observed that the other staff members slow to respond to the attacks. Within 3 minutes, the patient was manually restrained in a prone position, with 6 staff members holding the patient down on the floor. The staff did not utilize mechanical restraints, the restraint chair, or the med sled during the incident. The staff then unsuccessfully attempted to assist the patient to his feet. The patient remained manually restrained in a kneeling position. The staff members then dragged the patient to the seclusion room on his knees. Patient #4 6. The Investigator reviewed the medical record for Patient #4, who was admitted on 01/24/25. The review showed the following: a. On the Seclusion Record dated 01/24/25, staff documented when the patient was admitted at 9:40 AM, the patient was taken directly into locked seclusion by law enforcement officers after displaying manic, assaultive behaviors. The patient was released from locked seclusion at 10:58 AM after contracting for safety and exhibiting calm, cooperative behavior. Patient #4 was placed on 2:1 monitoring (two staff monitoring one patient) with DAP precautions. b. On the Code Gray Recording form dated 01/26/25 at 9:16 PM, nursing staff documented that the patient began posturing and insulting staff. The patient hit a clipboard out of the staff’s hands, then proceeded down the female patient’s hallway. Staff attempted to redirect the patient several times without success. A Code Gray was called, and additional staff arrived. The patient was walking near the seclusion room door, continuing to threaten and challenge the staff to fight. Staff initiated containment and the patient was taken to the seclusion room. 7. On 03/18/25 at 12:30 PM, the Investigator met with the Director of Security (Staff #4), to review Patient #4’s video footage from the incident on 01/26/25. The recording showed that the incident began at 9:13 PM. The Investigator observed the patient walking down the hallway with several staff members following him. The patient appeared to pause at the threshold of a room and turn towards the staff following him. Immediately there was an altercation between the patient and the staff. The patient was placed in a prone position on the floor and manually restrained by 8 staff members. The staff did not utilize mechanical restraints, the restraint chair, or the med sled during the incident. The staff then continued to manually restrain the patient (in the prone position), and 6 staff members carried him by his limbs to the seclusion room. 8. On 03/18/25 at 12:15 PM, during an interview with the Investigator, the Chief Nursing Officer (Staff #2) stated that after reviewing the video of the incident for Patient #1 that occurred on 01/26/25, they were able to see the FCA had his back to the patient and didn’t see him exit the room. Staff #2 stated that after the patient was manually restrained, they should have put the patient in restraints or used the med sled to safely pull the patient into the seclusion room. Staff #2 stated that staff should never pull, drag, or carry a patient with their limbs. 9. On 03/19/25 at 1:35 PM, during an interview with the Investigator, a Registered Nurse (RN4) (Staff #2) stated that the staff are directed to never pull, drag, or carry patients. Once the patients are contained, staff should place the patient in ambulatory restraints, use the restraint bed, med sled, or restraint chair. 10. On 03/19/25 at 3:30 PM, during an interview with the Investigator, a FCA (Staff #7) stated that he was performing the 2:1 monitoring for Patient #4 on 01/26/25. Staff #7 stated that the patient was threatening and trying to hit staff. The charge nurse called a Code Gray for additional staff support. Staff #7 stated that the staff needs more training and protocols for when a patient becomes assaultive and combative. 11. On 03/20/25 at 9:00 AM, during an interview with the Investigator, an RN4 (Staff #8) stated that when staff have a patient contained on the ground, restraints, a med sled or a restraint chair should be used. Staff #8 stated that the hospital has been conducting restraint training recently, teaching staff what to do and what not to do. 12. On 03/20/25 at 10:55 AM, during an interview with the Investigator, an RN4 (Staff #9) stated that during patient escalations or Code Grays, staff are taught to stabilize a limb. They are not supposed to drag patients at any time. During codes, staff should bring the bag of ambulatory restraints and bring the med sled or restraint chair. Staff #9 stated that there are several new employees at the hospital. Each new employee receives CPI training and training on the various restraint techniques, but it just takes experience to respond to these incidents. .”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 31000 Based upon documentation review, observations and staff interviews on November 27, 2023 between approximately 1430 and 1515 hours the facility has failed to maintain proper exit signage. This could potentially misdirect patients, staff, and/or visitors during an emergency. Findings include: The gates for emergency egress out of the FSU south fire stairwell were not clearly identifiable as exits. The above was discussed and acknowledged by the facility staff who immediately installed exit signage.”