Winnebago Mental Health Institute

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 53566 Based on record review and interview, the facility failed to trend, analyze causes, and implement data-driven preventive actions related to adverse events in 1 of 1 Quality Assessment & Performance Improvement (QAPI) programs reviewed and failed to conduct an internal investigation per policy for 1 (Patient #8) of 1 adverse event meeting the criteria of a sentinel event in a total universe of 96 adverse events reviewed. Findings include: The facility failed to trend, analyze causes, and identify or implement corrective actions regarding adverse events and failed to conduct an internal investigation for an adverse event identified as a “Critical Incident.” See tag A-0286.”

“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: 53566 Based on record review and interview, the facility failed to trend, analyze causes, and implement data-driven preventive actions related to adverse events in 1 of 1 Quality Assessment & Performance Improvement (QAPI) programs reviewed and failed to conduct an internal investigation per policy for 1 (Patient #8) of 1 adverse event meeting the criteria of a sentinel event in a total universe of 96 adverse events reviewed. Findings include: A review of facility policy 111.02 “Quality Assurance and Performance Improvement (QAPI) Plan” last revised 04/2025 revealed, “The purpose of the...plan is to develop, implement, and maintain and effective, ongoing, hospital-wide, data-driven, quality assessment, quality assurance, and performance improvement program. These ongoing initiatives will improve health outcomes, identify and reduce errors and enhance patient safety...II. Quality Management Activities...PI (performance improvement) activities track medical errors, adverse patient events...and...Analyze their causes...Implement preventive actions and mechanisms...Track performance...Provide feedback and learning throughout the hospital...III. Data Collection: The QAPI Plan incorporates quality indicator, patient care, and other relevant data...A. Data is collected to: Monitor the effectiveness and safety of services and quality of care; and 2. Identify opportunities for improvement and changes that will lead to improvement...E. Data is collected from...1. Adverse, near-miss, or other safety events; 2. Sentinel events...IV. Aggregating and Analyzing Data...C. Analysis is performed, at a minimum, for the following...6. Adverse patient events; V. Use of Data Analysis: A. Information from data analysis includes...2. Improve patient safety...3. Reduce the risk of sentinel events...VI. Quality Management Committee...is responsible for...1. Conducting meetings at least quarterly...7. Ensures appropriate action is taken when processes, outcomes, or improvements do not achieve or sustain expected results...” A review of facility policy 204.03 “Sentinel Event and Other Patient Safety Events” last revised 05/2024 revealed, “...A. Patient Safety event - an event, incident, or condition that could have resulted or did result in harm to a patient...Patient safety events include sentinel events, adverse events, no harm events, close calls, and hazardous conditions...B. Sentinel Event - is a patient safety event...that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm)...considers the following...to be sentinel events...11. Fall in a staffed-around-the-clock care setting resulting in any of the following...c. Required consult/management...for a neurological (for example...subdural or intracranial hemorrhage)...injury...A. Events are considered “sentinel” because they signal a need for immediate investigation and response. All sentinel events MUST be reviewed by WHMI...WHMI is expected to identify and respond appropriately to all sentinel events...An appropriate response includes all the following: 1. A formalized team response...2. Notification of WHMI leadership. 3. Immediate investigation. 4. Completion of a comprehensive systematic analysis...such as a Root Cause Analysis (RCA). 5. Strong corrective actions derived from the analysis that eliminate or contgrol system hazards or vulnerabilities and result in sustainable improvements over time. 6. Time line for implementation of corrective actions. 7. Systematic improvement...C. Timelines...1. Within 35 days of identifying an event as sentinel the comprehensive analysis of the event should be completed along with an action plan...Critical Incident Response. All critical incidents must be reported in accordance with policy and procedures outlined in 205.02 Incident Reporting. *Note - a sentinel event is a critical incident, however a critical incident may or may not be a sentinel event...Events resulting in the completion of an Incident Report are, by WHMI’s definition, “Adverse Events” and require that leadership be aware, identify trends and address risks, and respond to assure all that can be learned from an event is translated into new policy, procedure, or practice...Data, trending, and analysis is carried out by the Quality Department and brought to the Quality Management Committee and/or Clinical Excellence Team for periodic review and response..” A review of facility policy 205.02 “Incident Reporting” last revised 06/2024 revealed, “It is required that all unexpected or unusual events that are harmful or potentially harmful to patients...are reported to management...To improve services and operations, information from incident reports is analyzed and data are aggregated to identify trends and opportunities for improvement...Incidents - are unexpected or unusual events that are harmful or potentially harmful or have an unfavorable or potentially unfavorable outcome...Critical Incidents - are serious events wherein WMHI has evidence to support or other reason to believe one of the following has occurred...Serious injury or death of a patient/client that occurs during hands-on interaction with staff...B. Incident occurrences and trends are tracked by the Quality Department and discussed quarterly at the Quality meetings...D. If a Critical Event were to occur...3. The internal investigation of the event is to be immediately started if no external law enforcement investigation is initiated...8. The review of the incident shall be written and include the following components: a. Background and history of the incident...b. Relevant patient, resident, or inmate details...c. Details of staff action...d. Identification of strengths and areas of improvement...e. Plan for correction, if any, including timeline. 9. Results of the internal investigation are to be reviewed by the facility Director, Division Administration, and others as necessary before closing the event...” On 5/12/2026 starting at 10:25 AM, during a review of adverse events with EHR (Electronic Health Record) Analyst H and EHR Nurse I, noted that adverse events were documented only in Cerner (the facility’s electronic medical/health record system) and did not include details related to either the investigation or the subsequent outcome of the events. When asked to confirm where the facility investigation of adverse events was documented, both EHR Analyst H and EHR Nurse I stated they were unaware of any documentation other than the real-time, patient-specific documentation found in Cerner. Failure to trend, analyze, and implement preventive action related to adverse event data: A review of “Quality Management Meeting Minutes” from January 2025 to April 2026 revealed no evidence of discussion related to the trending, analysis, data, or action items related to adverse events or documented patient incident reports during quarterly QAPI meetings. Failure to investigate a Critical Incident level adverse event: A review of Patient #8’s medical record revealed: A review of “Patient Incident” written on 3/2/2026 at 3:48 PM by RN T revealed, “...Injury - Description: possible injury to the back of his head during takedown and placement on transboard (restraint board)...Requring medical care?: No. Seen by MD/PA/NP (Medical Doctor/Physician Assistant/Nurse Practitioner)?: No...[Patient #8] was upgraded from seclusion to transboard...[Patient #8] was combative during the process, resulting in PCT (Psychiatric Care Technician) staff and [Patient #8] falling into the wall. PCT staff expressed concerns that [Patient #8] may have hit his head...No bleeding, no swelling, no laceration. Neurological assessment initiated, however, [Patient #8] is not being cooperative with the assessment...” A review of Patient #8’s medical record revealed that between 3/2/2026 at 8:44 PM and 3/3/2026 at 10:25 AM, Patient #8 alternated between “alert” and “lethargic” during his neurological assessments. On 3/3/2026 at 10:25 AM, Patient #8 was transferred to an acute care hospital where he was intubated in the Emergency Department and later diagnosed with a subdural hematoma. Patient #8 did not return to the facility and was formally discharged on 3/6/2026. During an interview on 5/12/2026 at 10:40 AM, Deputy Director P stated that falls and incident reports are reviewed quarterly at the QAPI meetings. Deputy Director P stated, “We wouldn’t do an investigation or review on every single event here.” When asked if adverse events are tracked as part of quality improvement, Deputy Director P stated, “We have no real process for that. Adverse events are addressed on a patient-by-patient basis.” Deputy Director P stated, “The Sentinel Event policy means staff safety events, so we use the Incident Reporting” policy for patients. When asked to clarify the “Incident Reporting” policy and explain what it means to document incidents in “DHS Connect,” Deputy Director P stated, “DHS Connect is just our other name for Cerner. That’s the only place we document our incidents.” When asked what types of events would necessitate an RCA, Deputy Director P stated, “For sure elopement, a fall with a head bleed or send-out [to the hospital], or a suicide attempt.” When asked if Patient #8’s fall, hospital transfer, and subsequent subdural hematoma were investigated as an RCA, Deputy Director P stated, “Probably not.” During an interview on 5/12/2026 at 1:57 PM, when asked if the facility tracks or trends adverse events, DON (Director of Nursing) O stated, “There isn’t going to be a great log of that.” DON O stated she keeps a paper file folder of concerns and adverse events to review, which come to her “by word of mouth if they are bad enough to talk about.” When asked if facility staff keep documentation of investigation, trending, tracking, or outcomes of advsere events, DON O stated, “No, you probably wouldn’t find that.” When asked if data, trends, or action items related to adverse events are reported or discussed at QAPI meetings, DON O stated, “No.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50643 Based on record review and interview, the facility failed to implement interventions to protect patients from inappropriate restraint use in 1 of 1 known incidents of inappropriate restraint use (Patient #1), and facility staff failed to educate staff on physical hold techniques in 3 of 6 staff interviewed (Teacher A, Teacher M, Educator D). Findings Include: The facility failed to implement interventions to protect patients from inappropriate restraint use. - See Tag A-0145 The facility staff failed to educate staff on physical hold techniques. - See Tag A-0202”

“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: 50643 Based on record review and interview, the facility failed to implement interventions to protect patients from inappropriate restraint use in 1 of 1 known incidents of inappropriate restraint use (Patient #1). Findings include: A review of the facility’s policy titled “Reporting and Investigating Alleged Patient Abuse Procedure” last revised 8/2022 revealed, “...All allegations or incidents are thoroughly and impartially investigated internally, and documented by the assigned lead investigator... The supervisor will remove the accused employees from the patients involved... The HR Director will schedule a meeting with the Director, Deputy Director, and Department Director as available in order to review the findings of the completed investigation and determine the action to be taken including a return to work plan and identified training needed. Consideration should also be made to review the Performance Planning and Development expectations with the employee... and make clear any expectations for improved... the Director or designee makes the final decision as to whether or not discipline is warranted, and if so, at what level of disciplinary action... If the employee is to continue employment, the Department Director or Designee will determine any retraining or review needed by the employee. Training and review may be recommended regardless of whether discipline is given for a work rule violation, if the investigation reveals any area in which the employee’s skills need improvement...” Review of the facility “Misconduct Incident Report” on 3/13/2026 (no time) revealed allegations of an incident involving Patient #1 in which Teacher A performed untrained restraint techniques on 3/10/2026 including a 1-man escort, placing hands on shoulders, and pushing Patient #1 into a wall. “...Immediate Action Taken: This incident occurred at the end of [Teacher A’s] shift on 03/10/2026. [Teacher A] was informed by [HR (human resources) Director H] and [Leader I] at 06:00 AM on 03/11/2026 that he was being removed from direct patient contact. [Teacher A] was placed onto administrative leave at 12:30 PM on 03/11/2026...” Review of the Facility’s “ Employee Investigation Reports (EIR) -Chronological Log” revealed a timeline as follows: -3/10/2026: Teacher A allegedly escorted Patient #1 from the school to the unit and into the seclusion room and used untrained CPM techniques. -3/11/2026: Teacher A placed on administrative leave. -3/12/2026 - 3/25/2026: EIR leaders interviewed witnesses (Student Teacher L, PCT B, PCT E, PCT F, RN G) and Teacher A. -3/31/2026: Held Pre-Disciplinary Meeting with Teacher A. A review of the facility’s “Employee Investigation Reports (EIR) - Final Conclusion” on 4/1/2026 (no time) by Leader K revealed Teacher A performed untrained CPM (Crisis Prevention and Management) techniques on 3/10/2026 including a 1-man escort, placing hands on shoulders, and pushing Patient #1 into a wall. The investigation concluded that in doing these untrained CPM techniques, Teacher A did not adhere to several work rules by failing to follow policies related to restraints and CPM interventions. During an interview on 4/21/2026 at 9:25 AM, PCT B stated that when she witnessed Teacher A pushing Patient #1 towards the wall, she told him that mini-wraps would be needed, but Teacher A ignored her and pushed Patient #1 a second time toward the wall. PCT B stated that after the incident she spoke to RN Manager G who stated that Teacher A would need a CPM Refresher. During an interview on 4/21/2026 at 2:04 PM, Teacher A stated that he received a brief phone call on 4/17/2026 from HR Director H telling him he could return to work on 4/20/2026. Teacher A stated that he had been told that disciplinary decisions were still pending, and that he had not been told that he was not allowed to be alone with patients. During an interview on 4/21/2026 at 12:25 PM, HR Director H stated that the decision to have Teacher A return to work was made during an on-line leadership meeting. HR Director H stated that there were no notes taken during the meeting, and that there were no meeting minutes. HR Director H stated that the facility was waiting on a disciplinary decision from the “Central HR Office,” regarding whether Teacher A would be issued a 1-Day or a 3-Day suspension without pay. HR Director H stated that since leadership had determined that termination was not necessary, it would cause Teacher A undue stress to keep him on administration leave until the suspension decision was made, so he was allowed to come back to work on 4/20/2026. HR Director H stated that there were no work restrictions or patient contact restrictions implemented for Teacher A prior to his return to work date. During an interview on 4/21/2026 at 1:40 PM, Education Director D stated that Teacher A had been back in work status on 4/20/2026 and was working without restrictions. Education Director D stated that she had not had a conversation with Teacher A upon his return about not being alone with students, or about not using untaught or unapproved CPM techniques. During an interview on 4/21/2026 at 10:45 AM, Deputy Director J stated that Teacher A had returned to work on 4/20/2025. Deputy Director J stated that Teacher A was teaching students without restrictions 4/20/2026 through 4/22/2026, before completing a CPM Refresher on 4/23/2026.”

“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: 50643 Based on record review and interview, facility staff failed to educate staff on physical hold techniques in 3 of 6 staff interviewed (Teacher A, Teacher M, Educator D). A review of the facility’s policy titled, “Crisis Prevention and Management (CPM) Program” last revised 5/2024 revealed, “...(The Facility) is committed to protecting and promoting patients’ rights to receive care in a safe setting... The concept of team intervention to manage a potentially violent patient is recognized as providing safety for all involved... A crisis management involves interventions utilized by staff when less restrictive measures have been determined to be ineffective to protect the patient, a staff member, or others from harm... Crisis Management focuses on... minimizing risk to patients related to medical risk factors and physical positioning... Light Grasps - principle behind and how it differs from physical restraint... Seclusion or Restraint Policy... Alert System - explanation of the duress system and response to behavioral crisis situations... Physical and Mechanical Restraint - safe use and application... CPM interventions permitted for physical engagement include... Team escort... Wall containment... takedown... Floor containment... Staff who implement CPM techniques... shall receive training: During orientation... During CPM Refresher Training which is updated every 2 years and trained to all staff prior to implementation... Staff assigned to physically control the patient shall implement all techniques consistent with (The Facility) training, policies and procedures while protecting the patient’s safety and dignity...” A review or the facility’s “CPM Refresher” (no date) revealed, “Team Escort vs. Light Touch: A Team Escort is considered a restraint... physical restraint definition: A manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability or a patient to move his or her arms, legs, body, or head freely. Restraint also includes intent. If the goal is that the patient not get out of an applied physical restraint, it is considered a restraint even if the patient can get away from staff... Light Touch is not a restraint... light touch definition: A patient can easily remove or escape from a grasp or physical hold in the same matter as it was applied by staff, considering the patient’s physical condition and ability to accomplish this objective...” During an interview on 4/21/2026 at 2:04 PM, Teacher A stated that he would consider the one-arm hold that he used on Patient #1 a “light touch.” Teacher A stated that when he placed hands on Patient #1 in the seclusion room he would not consider it a push, but that it was not a technique that he had learned in CPM training. A review of the facility’s “Employee Investigation Reports (EIR) - Final Conclusion” on 4/1/2026 (no time) by Leader K revealed “[Teacher M] stated that ... one person placing hands on kids and delusional patients happens regularly. [Teacher M] stated that [Teacher A] should not be singled out and disciplined for a system problem because that would be unfair. [Teacher M] explained that [Teacher A] improvised and made judgement calls to keep [Patient #1] safe. [Teacher M] offered that if [Teacher A] did something wrong, he should not be disciplined but told what he can’t do, and the systemic problem addressed...” During an interview on 4/21/2026 at 12:50 PM, Teacher M stated that “light touch” is interpreted differently by all staff, and that it was unclear what constituted “light touch” in CPM training. During an interview on 4/21/2026 at 1:40 PM, Education Director D stated that she was unsure what “light touch” consisted of.”

“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: 47413 Based on record review and interview, facility staff failed to recheck a weight discrepancy per facility policy in 1 of 1 patients (Patient #1); facility staff failed to complete weekly weights as ordered in 2 of 10 patients (Patient #1, 5), and failed to complete intake monitoring for 2 of 5 patients (Patients #5, 11) with intake monitoring ordered in a total sample of 13 medical records reviewed. Findings Include: A review of the facility’s policy ID #16492173 titled, “Height/Weight/VS Monitoring” last approved 02/2024 revealed, “... 6... When the patient’s weight gain or loss is 5 pounds or greater than the previous weight, the RN (Registered Nurse) will ensure the patient is re-weighed to verify and confirm the weight gain or loss...” Example of failure to recheck a weight discrepancy: A review of Patient #1’s medical record revealed that she was a 27-year-old female with a history of schizophrenia admitted to the facility on 12/26/2025 involuntarily on a Chapter 51 hold for schizophrenia. A review of Patient #1’s medical record revealed that she was sent to an outside hospital (Hospital A) for medical clearance for jail on 12/24/2025 and was admitted to this facility on 12/26/2025. A review of Patient #1’s medical record revealed Hospital A’s medical clearance form, “ ... 12/24/2025 (no time) ... Admission Weight: Weight: 54.9 kg (kilograms) (121 lb (pounds)).” Admission weight documented by this facility on 12/26/2025 at 12:55 AM revealed, “Weight Measured; kg; 62.5” (137 pounds),” a discrepancy of 16 pounds from the previous weight. Review of the record revealed Patient #1’s weight was not rechecked per facility policy until 01/12/2026 (no time; 17 days later) which revealed Patient #1’s weight was documented as 50.2 kilograms (110 pounds). During an interview on 01/14/2026 at 10:58 AM RN Manager H stated, “That is definitely an inconsistency and she should have been re-weighed.” Examples of failure to complete weekly weights as ordered: A review of Patient #1’s medical record revealed an order for weekly weights on 12/26/2025 (no time). Review of the record revealed that Patient #1 was weighed on 12/26/2025 (upon admission) and not again until 01/12/2026 (17 days later). A review of Patient #5’s medical record revealed that she was admitted to the facility on 12/27/2025 for schizophrenia (a severe brain disorder causing a break from reality, characterized by distorted thinking, perceptions (hallucinations, delusions), and emotions). Review of the record revealed an order for weekly weights on 12/27/2025 (no time). Patient #5 was weighed on 12/27/2025 (upon admission) and not again until 01/10/2026 (14 days later). During an interview on 01/14/2026 at 10:58 AM RN Manager H stated that weights should be completed weekly. Examples of failure to complete 5 times a day intake monitoring as ordered: A review of Patient #5’s medical record revealed an order for 5 times a day intake monitoring for high risk for malnutrition on 12/29/2025 (no time). Review of the nursing flowsheet titled, “Food Intake Monitoring Flowsheet” revealed the following: On 12/31/2025, there was no documentation of Dinner or HS snack. On 01/02/2026, there was no documentation of Dinner. On 01/04/2026, there was no documentation of Dinner. On 01/05/2026, there was no documentation of Dinner. There was no evidence found that the physician or dietician was notified of Patient #5’s missed intakes. A review of Patient #11’s medical record that she was admitted to the facility on 12/19/2025 for suicidal ideation. Review of the record revealed an order for 5 times a day intake monitoring on 12/19/2025 (no time) for history of food refusal. Review of the nursing flowsheet titled, “Food Intake Monitoring Flowsheet” revealed the following: On 12/25/2025, there was no documentation of PM snack. On 12/28/2025, there was no documentation of PM snack. On 01/02/2026, there was no documentation of Lunch. On 01/04/2026, there was no documentation of PM snack. On 01/06/2026, there was no documentation of PM snack, and Patient #11 refused Breakfast, Lunch, Dinner. On 01/07/2026, there was no documentation of PM snack, and Patient #11 refused Breakfast, Lunch. On 01/13/2026, there was no documentation of PM or HS snack. There was no evidence found that the physician or dietician was notified of Patient #11’s missed or refused intakes. During an interview on 01/14/2026 at 1:15 PM with RN Manager H, she stated that staff need to be documenting 5 intakes (snacks, meals, fluids) a day, if it is ordered for that patient. During an interview on 01/14/2026 at 1:45 PM with Director L, she stated that the facility does not have a specific policy on the frequency of intake monitoring, but that staff should be following the doctor’s order for intake monitoring. During an interview on 01/14/2026 at 3:35 PM with Dietician G, she stated, “If there are missing or refused intakes, we want nursing staff to consult us.””

“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: 47413 Based on record review and interview the facility failed to immediately report an allegation of caregiver abuse/misconduct in 1 of 1 caregiver misconduct allegations reviewed (Patient #1) in a total sample of 1 caregiver misconduct allegations reviewed. Findings Include: A review of the facility’s policy titled, “Reporting and Investigating Patient Abuse Procedure” last revised 08/2022 revealed, “... The employee who suspects abuse... must immediately contact the RN (Registered Nurse) on the unit to report the alleged abuse...” A review of the facility’s policy titled, “Crisis Prevention and Management Program” last revised 05/2024 revealed, “... Interventions Not Permitted: ... Any application of undue pressure to any part of a patient’s body ... “ A review of Patient #1’s medical record revealed that Patient #1 was a 59-year-old male with a history of altered mental status who was admitted to the facility on 02/25/2025 at 1:57 AM under a court order for treatment after he was found at a train station wandering around and was admitted for catatonia (a psychomotor disorder characterized by unusual movements, behaviors, and a disconnection from the environment- can also present as confusion, restlessness and agitation). Patient #1 remained a “1:1” status for his admission because he was considered a “high fall risk.” Patient #1 was discharged from the facility with his guardian on 03/20/2025 at 8:29 AM. A review of the facilty’s document titled, “Employee Investigation Reports” revealed that PCT (Psychiatric Care Technician) A performed an untrained CPM (crisis-prevention-management) technique on Patient #1 on 02/28/2025 when he held Patient #1 down in their bed by their shoulders and this was witnessed by PCT G at approximately 1:00 AM. Review of the “Employee Investigation Reports” revealed that PCT G did not report the alleged abuse by PCT A to Patient #1 until approximately 3:00 AM-4:00 AM. During an interview on 04/18/2025 at 9:35 AM with DON (Director of Nursing) I, when asked about abuse reporting, DON I stated, “I expect that it would be reported right away.””

“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: 47413 Based on record review and interview, facility staff failed to perform a nursing assessment and evaluate a patient after alleged abuse in 1 of 1 patients (Patient #1) in a total sample of 1 caregiver misconduct allegations reviewed. Findings Include: A review of the facility’s policy titled, “Reporting and Investigating Alleged Patient Abuse Procedure” last revised 08/2022 revealed, “... [Hospital name] employees... must follow the following steps if they suspect possible occurrence of patient abuse: ... The RN (Registered Nurse) will conduct a physical assessment when applicable to assess for any injuries...” A review of the facility’s “Employee Investigation Reports” revealed that PCT A performed an untrained CPM (crisis-prevention-management) technique on Patient #1 on 02/28/2025 when he held Patient #1 down in their bed by their shoulders and this was witnessed by PCT (Psychiatric Care Technician) G at approximately 1:00 AM. A review of Patient #1’s medical record revealed: “Assessment” on 02/28/2025 at 5:30 AM by RN V (approximately 4 hours after the incident occurred): “Neurological: Level of Consciousness: Alert; Psychosocial: ... Behavior: Calm, Cooperative.” Review of “Shift Summary” on 02/28/2025 at 5:30 AM by RN V revealed: “1:1 supervision continues for safety. Slept well. No behavioral issues ... Assessed and met needs, Communicated with physician, Encouraged to seek out staff assistance if needed ...” Review of Patient #1’s medical record revealed there were no further physical assessments documented on Patient #1 such as a comprehensive physical assessment, pain level, or vital signs after the abuse occurred. During an interview on 04/18/2025 at 9:36 AM with DON (Director of Nursing) I, when asked what the nursing assessment process is after suspected abuse has occurred, DON I stated, “I would expect to see more of a physical assessment from the nurse.””