Granite Hills Hospital

“EMERGENCY SERVICES CFR(s): 482.12(f)(2) If emergency services are not provided at the hospital, the governing body must assure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate. This Standard is not met as evidenced by: 52276 Based on record review and interview, facility failed to complete a facility to facility transfer with doctor to doctor contact and receiving facility acceptance for 1 of 1 transferred patients (Pt. #1), in a total sample of 20 patient records reviewed. Findings: Review of the facility’s policy “Emergency Medical Transfer,” #20736479 last revised 9/10/2026 with a last approval date of 6/10/2026 revealed, “ ...6. The patient is transferred only when the receiving hospital/facility has consented to the transfer, and the patient is considered sufficiently stabilized for transport.” Review of Pt. #1’s medical record “LATE ENTRY: Transfer for Medical Clearance” written on 5/8/2026 at 8:42 AM by RN Intake Clinician D revealed, “Patient arrived in Sally port and is unable to transfer to chair. States ‘patient reports he us unable to ambulate and reports that he usually use [sic] a motorized wheel chair to propel himself around.’ Write updated facility supervisor ...Patient noted to have change in condition from clinicals received to facility ... ‘patient reports being in bed for 17 hours per day, up for three hours with assistance of a care giver that comes into the home’ ... ‘I can’t transfer myself, I need help of others to transfer and completed ADL’s’ ...Upon report to CEO of above note, writer instructed to send patient out to (Hospital C). Instructed to call (entity name) ambulance non-emergency and alert of patient need to be sent to (Hospital C) for ER staff assessment for inability to self-transfer and complete ADL’s independently ...” During interviews on 6/10/2026 at 9:30 AM, Intake Clinicians D, E, and F stated, if a patient gets to the sally port and presents differently than what was reported by the sending facility, an assessment would be completed, and the MD (Medical Doctor) would be updated as well as the supervisor. If it was determined the patient could not stay at the hospital, the MD would get acceptance, complete a doctor to doctor and a transfer form would be filled out before the patient was transferred out. There are no transfer documents for Pt #1 to be transferred to Hospital C. During an interview on 6/10/2026 at 11:45 AM with CEO E, he stated the RN that transferred the patient stated she forgot to make sure the acceptance/doctor to doctor part of the transfer was complete.”

“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: 44431 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: Review of the facility policy titled, “Caregiver Misconduct Management” dated 01/30/2024, revealed, “Staff and all other persons whom clients/patients come in contact shall treat the client/patient with courtesy, respect...shall provide them considerate care and treatment at all times... K. Abuse 1. An act...by a caregiver, including but not limited to restraint...that when contrary to...policies and procedures, when not a part of the patient’s treatment plan... a. Causes or could reasonably be expected to cause pain, injury...B. Initial Assessment/Notification: 1. All staff and covered entities witnessing or having knowledge of... or possible alleged caregiver misconduct will report it immediately to the entities and their respective manager, including immediately contacting the respective [Hospital Name] Administrator on call if applicable. a. Prior to the call being made a plan of safety shall be executed immediately by the RN manager/Supervisor/designee to ensure the safety of the patient. d. ...House Supervisor on Duty will immediately contact the appropriate [Hospital Name] Administrator on Call Staff to ascertain and determine how investigations within the hospital will be conducted.” Patient #1 was a 35-year-old male who presented to the facility voluntarily on 06/16/2025 at 1:41 PM due to worsening depressive symptoms with active suicidal ideation. A review of the facility’s investigation summary involving Patient #1 revealed on 06/25/2025 at 11:00 PM Patient #1 was barricading door and exhibiting behaviors of increased agitation and self harm. Staff interventions were ineffective. On 06/25/25 at 11:20 PM Patient #1 was placed in a secure hold and received chemical restraint. On 06/26/25 at 12:05 AM Patient #1 was sent to the ED for treatment and evaluation of self inflicted wound. On 06/26/25 at 4:30 AM CNO (Chief Nursing Officer) was informed of the event, an investigation was started. On 06/26/2025 in the AM (No actual time documented) involved staff were suspended by leadership pending investigation. Further review of the investigation revealed that Patient #1 was being held by two staff members who did not utilize proper CPI (Crisis Intervention Institute) training techniques, “By holding hands over mouth and pursing head into mattress.” During the investigation process it was identified there were concerns about Milieu Specialist F’s approach and making inappropriate statements which escalated Pt. #1’s behavior. There was no evidence found that the facility staff reported the inappropriate hold or behavior to facility leadership until over 5 hours later. On 08/12/2025 at 4:00 PM in an interview with CNO E when asked what was done to ensure patient safety and why this incident wasn’t reported immediately to leadership CNO E stated, the incident that occurred on 06/25/2025 at 11:00 PM was brought to his attention on 06/26/25 at around 4:30 AM and an investigation was started. CNO E stated the investigation identified the staff involved acted inappropriately and, “This behavior is not tolerated.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 29963 Based on record review and interview facility staff failed to remove medication from patient access when completing the intake process for 1 of 4 Patient (#7), which resulted in Pt. #7 being transported by EMS (Emergency Medical Services) for treatment of a drug overdose, and failed to document 15-minute checks were completed for 1 of 4 Patient (#7) in a total of 4 patients during admission to the facility. Findings Include: Facility staff failed keep a patient safe by removing medication from patient access and failed to document 15-minute safety checks per policy. See tag A-0144. 52395”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 44431 Based on record review and interview the facility failed to document refusal of food and fluids and failed to assess nutrition and fluid status in 14 of 16 patients which resulted in Patient (Pt.) #4 requiring transfer to a higher level of care for dehydration and failed to assess 1 (Pt. #1) of 16 medical records for the reason for and after giving as needed medications. This failure to assess nutrition and fluid status and failure to assess the reason for and after giving as needed medications has the potential to impact all patients hospitalized at the facility. Findings Include: The facility failed to follow their daily nursing assessment policy, failed to assess Pt. #24 for suicide risk and failed to assess nutrition and fluid status as per policy. See Tag A-395 The facility failed to follow their medication administration policy, failed to assess Pt. #1 for the reason for and after giving as needed medications. See Tag A-405”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 44431 Based on record review and interview the facility failed to have a process to evaluate the facility discharge program for 1 of 1 discharge programs reviewed, failed to follow their discharge policy to provide complete discharge information for 1 Patient (Pt.#1) out of 16 records reviewed and failed to provide discharge transfer information for 3 Patients (Pt. #2, #4 and #24) out of 3 records reviewed transferring to a higher level of care. Findings: The facility failed to have a process to evaluate the discharge program for 1 of 1 discharge programs reviewed. See Tag A-803. The facility failed to provide complete discharge education and transfer information per policy. See Tag A-813.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 29963 Based on record review and interview facility staff failed to keep a patient safe by removing medication from patient access when completing the intake process for 1 of 4 Patient (#7) which resulted in Pt. #7 being transported by EMS for treatment for a drug overdose, and failed to document 15-minute checks were completed for 1 of 4 Patients (#7) in a total of 4 patients during admission to the facility. Findings Include: A review of the facility form titled, “Client Rights” effective 09/2024 revealed, “When you receive inpatient ... services for mental illness ... you have the following rights ... Your surroundings must be kept safe and clean ...” A review of the facility policy #17598868 titled, “Admission Process for the Voluntary and Involuntary Patient” dated 02/13/2025 revealed, “B. Arrival and Admission of Voluntary Patients: 1. Patient presents to the hospital’s Intake Department. 2. The patient will place their belongings in a bag and give the belongings to the in the Intake staff. Once completed the patient does not regain access to belongings until discharge or until the belongings inventory is completed for admission to ensure the safety of the patient and others.” A review of facility policy #14948866 titled, “Belongings Management Process” dated 10/09/2024 revealed, “B. Belongings Management 1. Upon entering the Intake Area, the patient will place all belongings in the a (sic) locked area provided by [Psych Hospital]. This includes luggage, clothing, purses, backpacks, bags, and any other item brought into the hospital. 3. After an admission order has been received, the patient’s belongings are retrieved from the locked area ... 4. Medications are placed in a drop safe by the Intake Staff to be removed and reviewed by pharmacy before being stored on the unit for storage ...” A review of facility policy #16358123 titled, “Patient Observation Rounds/Level of Observation” dated 08/06/2024 revealed, “It is the policy of [Hospital] to uphold the right of our patients to receive care in a safe and therapeutic environment. Patients are routinely observed in compliance with physician orders and/or prescribed protocols. Staff members assigned to each patient will provide monitoring, precautions, oversight and intervention to provide for their safety and security ... 1. Patient Observation Rounds will begin upon patient arrival to [Hospital] ... 2. Transfer admissions will be brought directly to the Intake Department where Patient Observation rounds will be immediately initiated by the Intake Staff utilizing a paper rounding sheet until the patient has been established to the hospital at which time a beacon (tamper resistant bracelet worn by patients to record safety rounds) will be paired and placed on the patient and Patient Observation Rounds will be transferred to the ObservSMART tablet ... 5. Level of Observation: 1. Q (every) 15 minutes Observations. Staff assigned to complete patient observation rounds will: a. Log in to the ObservSMART tablet and review their rounding assignment and begin documenting observations ... c. Observe each patient a minimum of every 15 minutes ... and document observation on the observSMART tablet.” A review of Patient #7’s “Direct Admission Assessment” form dated 03/24/2025 at 12:55 PM revealed, “Voluntary admission of a 15-year-old female with complaints of suicidal ideation. Plan to jump out of a window. History of PTSD (Post Traumatic Stress Disorder), depression, anxiety and self-harm.” A review of facility “Incident Report” for Patient #7 revealed, “Date of Incident: 03/24/2025 Time: 2:10 PM ... As the writer was walking patient to unit 5, she endorsed not feeling good. Shortly after pt (patient) projectile vomited and told this writer that she tried to overdose. Writer inquired about when, the patient said when she was in the assessment room. Patient was helped to the unit EMS were called. Meds (medications) were found in brown paper bag that was given to patient at unknown time.” A review of the video of Patient #7 in the intake department in the assessment room on 03/24/2025 beginning at 1:22 PM was completed. The video of Patient #7 revealed the following: Patient #7 was sitting in the assessment room in a chair. There was a large brown bag sitting on the table. The door of the assessment room was propped open with a chair. Patient #7 was observed at: 1:22 PM- eating snacks 1:26 PM- left room to get more snacks 1:28 PM- left room to use bathroom 1:32 PM- observed looking in brown paper bag sitting on table in assessment room. Patient #7 grabbed gallon bag filled with bottles of medication. Looked at bottles of medication and put them back into brown bag. 1:33 PM- observed removing medications from brown paper bag, taking medication out of gallon bag, and taking pills out of medication containers and setting medications on table. 1:34 PM- medications containers were placed back into brown paper bag. Patient #7 grabbed the medication sitting on the table and put them in her mouth. 1:35 PM- Intake coordinator T walked into room and provided Patient #7 a journal and a stress ball. 1:36 PM- Intake coordinator T provided Patient #7 a cup of water. 1:37 PM- Patient #7 resting head on table. 1:38 PM- standing and throwing ball against wall. 1:41 PM- sitting in chair eating snacks. 1:43 PM- removed a book from the brown paper bag. 1:47 PM- resting in chair 2:08 PM- Patient #7 left the room with Intake Coordinator T. 2:15 PM- Arrived at adolescent unit- 15-minute checks began with beacon. A review of Patient #7’s “15-minute check form” that is completed in the intake department included checks being completed every 15 minutes from 03/24/2025 at arrival time of 12:00 PM through 1:15 PM (documentation indicated the beacon was placed on Patient #7 at 1:20 PM). Review of Patient #7’s “Behavioral Health- Patient Observation Sheet” revealed, 15-minute checks starting at 2:15 PM through 3:30 PM. There was no documentation of 15-minute checks from 1:20 PM through 2:15 PM. During an interview on 04/22/2025 at 8:59 AM, Director of Intake I stated when a new admit is brought to the facility a metal detector is used to check person and clothing. Medications are taken and placed in a white bag, folded over and stapled. The white bag is then placed in the safe for pharmacist to pick up. During an interview on 04/22/2025 at 9:23 AM, Lead Receptionist J stated when a patient is brought in the front entrance a wand is used to check for contraband. Belongings are locked up in a locker including medication. During an interview on 04/22/2025 at 9:46 AM, Intake Coordinator L stated the staff is trained on the intake process including checking the belongings of all patients. Intake Coordinator L stated when patients bring in medication they need to be taken and placed in a white bag and put in the safe. The patient should never be left alone with medication. During an interview on 04/23/2025 at 8:15 AM, Intake Coordinator L stated she was working when Patient #7 was admitted to the facility. Patient #7 was brought to the facility by family. They entered the building through the main lobby. [Patient #7] was a direct admit from a hospital. Intake Coordinator L stated she went through her belongings, the patient only had a bra, underwear and a book. The belongings were placed in a brown paper bag. Intake Coordinator L stated the family member had a gallon bag a medication. They were encouraged to take them home, but they were adamant about the medications being left at the facility. Intake Coordinator L stated she was not aware that the medications had been placed in the brown paper bag with the other belongings. Intake Coordinator L stated she picked up the paper bag and gave the bag to the patient as she thought the bag only contained the few pieces of clothing and a book. During an interview on 04/23/2025 at 12:01 PM, Intake Coordinator T stated she was working in the intake area when Patient #7 was admitted to the facility. Intake Coordinator T stated she that patients do not typically have personal items in the assessment room during the intake process. Intake Coordinator T stated she didn’t look in the brown bag, so she was not aware that medications were mixed with personal belongings. Intake Coordinator T stated medications are usually separated from the patient immediately and put in a small white paper bag and stored in the pharmacy drop safe. Intake Coordinator T stated it was also brought to her attention that 15-minute checks were not documented on Patient #7 per facility policy. During an interview on 04/24/2025 at 11:07 AM, Director of Intake I stated the staff identified that proper rounding was not documented on Patient #7.”

“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: 44431 Based on record review and interview the facility failed to assess 1 of 8 Patients (Pt. #24) for suicide risk, failed to document refusal of food and fluids and failed to assess nutrition and fluid status in 14 of 16 patients (Pt. #1, #2, #3, #4, #5, #6, #9, #10, #11, #17, #18, #19, #20 and #24). This failure to assess nutrition and fluid status has the potential to impact all patients hospitalized at the facility and resulted in Pt. #4 requiring transfer to a higher level of care for dehydration. Summary: Pt. #4 was a 21 year old admitted involuntarily as a Chapter 51 (temporary legal hold) on 3/17/2025 and was discharged on 03/24/2025. Pt. #4 had a diagnosis of bipolar disorder (mental disorder with severe mood swings) and suicidal tendency. Pt. #24 was a 41 year old admitted involuntarily as a Chapter 51 on 02/17/2025 and discharged on 02/26/2025. Pt. #24 had a history of seizures, depression, paranoia and suicide intent. Findings: Review of facility policy #14954290, last reviewed 07/31/2024 titled, “Initial Nursing Admission Assessment,” revealed, “Upon admission...each patient will be assessed by a registered nurse within eight (8) hours of admission to identify patient health care needs, and to guide the delivery of nursing care based on an analysis of information gathered....The Registered Nurse....interviews the patient, and collects and interprets data including...height, weight, vital signs, nutritional status...additional assessment data: Self-Injury/Suicide Assessment...when a patient is unable or unwilling to participate in the initial nursing assessment process, the nurse will gather as much information as possible to determine an initial plan of care and treatment. A unit nurse will then check every shift for patient’s ability to provide information enabling the nurse to complete the incomplete portions of the “Nursing Assessment.” Review of facility policy #14954192, last reviewed 07/31/2024 titled, “Daily Nursing Assessment and Progress Note,” revealed, “Nursing staff members are responsible for documenting clinical observations and care that he/she delivers/provides to each patient. Documentation by Nursing staff members shall be thorough, concise, accurate and will reflect the nursing process and the individual patients’ response to the goals and interventions...what to chart....symptoms: using the person’s own words, communication gestures, or non-verbal cues as much as possible...observations...interventions...illnesses and unusual health situations..nursing assessment; nursing care provided...any changes in condition in vital signs, refusal of meals, fluids.” Review of facility policy #14949628, last reviewed 07/17/2024 titled, “Proper use and Monitoring of Physical/Chemical Restraints and Seclusion,” revealed, “The patient shall be assessed and monitored every 15 minutes while in....seclusion by the RN assigned/trained staff..fluids...shall be offered at least every two hours...meals shall be offered at regular meal times.” Review of facility policy #15186182, last reviewed 02/07/2024 titled, “Nutritional Assessment/Consult,” revealed, “Nutrition screening will be completed for all patients at the hospital within eight (8) hours of admission by nursing.” Review of facility policy #14954445, last reviewed 07/16/2024 titled, “Medical Risk-Acute Change of Condition,” revealed, “To identify warning signs of clinical deterioration in a patient’s medical condition in order to provide early response to treatment that may patient [sic] mortality...When the clinical nursing staff identify symptoms in a patient that constitute a medical risk/acute change of condition they will proceed with the following steps:...Nursing staff will document the symptoms and interventions in the patient’s clinical record to include:...chronology of events including the onset of symptoms, vital signs, description of symptoms and condition. Measures taken or treatment implemented...notify the patient’s parent/guardian or emergency contact of the change in patient status.” Failure to assess suicide risk: Review of Pt. #4’s medical record revealed the suicide assessment completed on 03/17/2025 at 9:10 PM revealed entire assessment was documented as UTA. Review of Pt. #24’s medical record revealed a history of seizures, depression, paranoia and suicide intent, no suicide assessment was completed. Failure to assess food and fluids: Review of Pt. #4’s nursing admission assessment no date or time of completion revealed multiple sections of UTA (Unable to Assess), no evidence of a nutrition assessment was completed and no evidence of vital signs being taken until 3/19/2025 at 9:11 AM. (48 hours after Pt. #4 was admitted). There was no evidence Pt. #4 was monitored for food or fluids or assessed for symptoms of dehydration throughout their hospitalization. Review of Patient #4’s medical record revealed Pt. #4 was placed in seclusion for sexual aggression, inappropriate behavior, agitation, bizarre and uncooperative behaviors on: 03/21/2025 from 12:55-1:50 PM a total of 55 minutes 03/21/2025 from 4:05 - 6:46 PM a total of 2 hours and 40 minutes 03/22/2025 from 4:52-6:18 PM a total of 1 hour and 26 minutes 03/22/2025 from 8:02 -10:43 PM a total of 2 hours and 41 minutes 03/23/2025 from 9:35 - 11:45 AM a total of 2 hours and 10 minutes There is no documentation present if Pt. #4 received or was offered fluids or meals while they were in seclusion. There is no documentation of food or fluid consumption or refusal of food or fluids present in Pt. #4’s medical record throughout their hospitalization at the facility from 03/17/2025-03/24/2025 (7 days). Pt. #24 was hospitalized from 02/17/2025 through 02/26/2025 (9 days) and no evidence of food or fluid consumption was documented during their hospitalization. Pt. #24 required an IM injection of Thorazine and Ativan on 02/24/2025 and was placed in seclusion for 57 minutes and was not offered fluids while in seclusion Pt. #24 had a seizure while hospitalized and was transferred for a higher level of care on 02/25/2025 and then returned to the facility. Review of Pt. #24’s medical record revealed no nutrition assessment was completed. Review of medical records for Patients #1, #2, #3, #4, #5, #6, #9, #10, #11, #17, #18, #19 #20 and #24 revealed no evidence of patients being assessed for food or fluid consumption or refusal of food throughout their hospitalizations and no admission nutrition assessments were completed. On 04/24/2025 at 2:26 PM in an interview with Chief Nursing Officer (CNO) V when asked if they would expect to see something documented about refusal of food or fluids, V stated, “I would.” On 04/24/2025 at 3:20 PM in an interview with CNO V when asked if it was accurate there was no documentation of meal consumption, V stated, “There is no documentation of meal consumption, agree that is concerning.” On 04/30/2024 at 12:13 PM in an interview with Nursing Manager EE when asked what is the expectation to use UTA when assessing a patient, EE stated, “We don’t have anything that talks about it, staff should always redo it, I don’t believe we should ever see a UTA.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 44431 Based on Record Review and interview the facility failed to assess 1 (Pt. #1) of 16 medical records reviewed for the reason for and after giving as needed medications. Summary: Patient #1 was a 14 year old admitted voluntarily on 02/26/25 through 03/12/2025 following a suicide attempt. Pt. #1 had a history of multiple hospitalizations for suicide attempts, depression, anxiety and anger management. Findings: Review of Facility policy #15018754 titled, “Medication Administration,” effective date 01/10/2024 revealed, “All indications for the use of the medication will be documented appropriately in the Medication Administration Record...PRN [as needed] medications require reassessment to determine effectiveness of medication with measurable results....This should be documented on the MAR (Medication Administration Record).” Review of Pt. #1’s Medication Administration Record (MAR) revealed Pt. #1 had Vistaril 25 mg as needed for anxiety up to 4 doses daily, Zyprexa 5 mg as needed for mood every 8 hours as needed up to 3 doses daily and Melatonin 3 mg for sleep as needed at bedtime. Pt. #1 received the following PRN medications: Vistaril 25 mg oral was given as needed on 2/27/25 at 1:44 PM, 2/28/25 at 1:51 PM, 3/3/25 at 9:15 AM, 3/4/25 at 4:18 PM, 3/7/25 at 5:01 PM, 3/8/25 at 9:25 AM, 3/9/25 at 10:07 AM, 3/10/25 at 10:28 AM and 9:23 PM, 3/11/25 at 7:29 PM and on 3/12/25 at 9:00 AM Zyprexa 5 mg oral was given as needed on 2/27/25 at 1:45 PM, 2/28/25 at 1:51 PM, 3/3/25 at 4:19 PM, 3/4/25 at 9:12 PM, 3/8/25 at 9:33 AM and 5:27 PM, 3/11/25 at 7:29 PM and 3/12/25 at 9:55 AM Melatonin 3 mg oral was given as needed on 2/28/25 at 8:47 PM, 3/5/25 at 8:29 PM, 3/7/25 at 8:47 PM, 3/8/25 at 8:48 PM and 3/10/25 at 9:23 PM. Review of Pt. #1’s medical record, medication administration record revealed no evidence of indications for or reassessment completed or documented when PRN medications were administered during their hospitalization. On 04/22/2025 at 3:44 PM in an interview with Registered Nurse GG, GG stated that patients are assessed with the morning and afternoon medication passes and as needed for PRN medications.”

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 44431 Based on Record Review and Interview the facility failed to have a process to evaluate the facility discharge program for 1 of 1 discharge programs reviewed. Findings: Review of Facility Discharge program revealed no evidence of a policy or procedure that addresses periodic review of patient discharge plans including those readmitted within 30 days of a previous admission. On 04/30/2025 at 4:21 PM in an interview with Chief Clinical Officer FF who oversees social services and discharge planning, when asked how the discharge process is reviewed for effectiveness, FF stated, “I review with the staff involved, we do discharge audits every month to make sure everything is done.” When asked if this review includes a review of the 30 day admissions, and if there is a process to review the 30 day readmissions, FF stated, “No. We discuss it clinically.” Chief Clinical Officer FF was unable to provide any documentation about how they evaluate the discharge program.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 44431 Based on record review and interview the facility failed to provide a medication list upon discharge for 1 Patient (Pt. #1) out of 12 records reviewed and failed to provide discharge transfer information for 3 Patients (Pt. #2, #4 and #24) out of 4 records reviewed transferring to a higher level of care. Summary: Patient #1 was a 14 year old admitted voluntarily on 02/26/25 through 03/12/2025 following a suicide attempt. Pt. #1 had a history of multiple hospitalizations for suicide attempts, depression, anxiety and anger management. Patient #2 was a 15 year old admitted involuntarily on 03/05/2025 through 03/10/2025 following an unsuccessful suicide attempt to shoot herself. Pt. #2 was recently discharged in February 2025 from this facility for similar concerns. Pt. #2 was discharged on 03/10/2025 to another psychiatric facility for a higher level of care due to repeated suicide attempts and behaviors while hospitalized. Patient #4 was a 21 year old admitted involuntarily as a Chapter 51 (temporary legal hold) on 3/17/2025 and was discharged on 03/24/2025. Patient #4 had a diagnosis of bipolar disorder (mental disorder with severe mood swings) and suicidal tendency. Patient #24 was a 41 year old admitted involuntarily on 02/17/2025 through 02/26/2025 with a history of seizures, depression, paranoia and suicide intent. Findings: Review of facility policy #14949024, last reviewed 01/30/2024 titled, “Discharge Planning Process,” revealed, “The development of a Discharge Plan begins upon admission and is a continuous process...The individual’s demonstrated readiness for discharge should be linked to the achievement of the multidisciplinary treatment goals....the multidisciplinary treatment team will develop aftercare plans on all individuals...The discharge/aftercare plan should: Prepare the individual and family for the transition to the next level of care...address the individual’s and family’s need for instructions about continued treatment...delineate how progress made in the current level of care will continue after discharge...identify the responsibility for ensuring that the prescribed follow-up care is accomplished...include timely and direct communication with and transfer of information to other programs, agencies or individuals that will be providing continuing care...The discharge/aftercare plan should define the following:...the level of care which the individual will be discharged to...a listing of all medications that the individual is to continue taking after discharge and...method for obtaining medications...follow up appointments...referrals...Discharge/aftercare plans and information on prescribed medications are communicated to the individual and family...and documented appropriately in the individuals electronic medical record. Discharge/aftercare plans are to be signed by the individual to acknowledge receipt and understanding of the information. The individual receives the original copy of the form at time of discharge/transfer. The Social Worker....designee will also fax or mail a copy of the forms to the next provider of care. This will occur for all internal transfers from one level of care to another....and for all referrals to providers in the community responsible for continuing care...All documentation related to discharge planning will be reflected in the individual’s medical record.” Review of facility policy #14726135, last reviewed 07/10/2024 titled, “Discharge Process-Department Roles,” revealed, “The discharge procedure is a multidisciplinary task that is to be completed by the members of the treatment team. This includes communicating the coordination of discharge planning with the individual, their family, natural supports and other person who may be involved in their care....The nurse will assist the individual in....reviewing and understanding discharge instructions and aftercare plan...reviewing and understanding the discharge medications/medication reconciliation. Review of Pt. #1’s medical record discharge summary on 03/12/2025 revealed Pt. #1 signed their discharge plan which included a listing of follow up appointments, crisis safety plan, Columbia suicide assessment, and health related social needs screening, there was no evidence of a signed discharge medication list provided to Pt. #1. Review of Pt. #2’s medical record revealed they were a 15 year old with a history of suicide attempts and multiple attempts while hospitalized. Pt. #2’s discharge summary completed by Doctor AA on 03/10/2025 at 2:00 PM revealed, “According to nursing reports, patient tried to kill herself on the unit yesterday evening...required medical intervention and was transferred for acute medical stabilization...at the time of discharge, lethality was denied and psychosis resolving. Mood and anxiety were well managed...patient was seen and evaluated on the day of discharge and deemed to be absent credible lethality and had achieved the maximum benefit from an inpatient hospitalization, so was discharged. Patient transferring to [a higher level of care facility]. Review revealed no evidence of a transfer form, or information sent to the receiving facility indicating Pt. #2’s condition or why they were transferred. Review of Pt. #4’s Discharge Summary on 3/24/2025 revealed, “At the time of discharge, pt had been moved to a higher acuity unit due to psychotic behaviors, had apparently become dehydrated and was sent out to a medical facility for treatment and observation where he was admitted.” Discharge diagnosis were, “Bipolar disorder, current episode manic, severe with psychotic features.” Review of Pt. #4’s discharge paperwork revealed pages 3-5 were missing and there was no evidence of a completed transfer form , MOT (Memorandum of Transfer) or status of patient’s medical condition at the time of transfer. Review of Pt. #24’s medical record revealed a history of seizures, depression, paranoia and suicide intent. Pt. #24 was hospitalized from 02/17/2025 through 02/26/2025. Pt. #24 had a seizure while hospitalized and was transferred for a higher level of care on 02/25/2025. There was no evidence of a transfer form being completed when a higher level of care was required. On 04/22/2025 at 2:39 PM in an interview with Social Work/Discharge Planner P, when asked what patients receive when they are discharged home, Discharge Planner P stated, “They get a copy of all of the discharge planning information, medications, it is reviewed with the patient and family by the nurse.” On 04/30/2025 at 3:40 PM in an interview with Director of Risk H, when asked if a memorandum of transfer form should be used with for patients transferring to a facility or higher level of care, H said, “Yes.” When asked if it was correct that [Pt. #2, #4 and #23] were missing transfer forms when they were discharged or transferred, Director of Risk H stated, “That would be correct.””

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 47413 Based on observation, record review and interview, facility staff failed to accept the transfer of 1 of 4 patients (Patient #1) who required inpatient psychiatric treatment in a total sample of 20 medical records reviewed. Findings Include: A review of the facility’s policy titled, “Emergency Services and Patient Transfers- EMTALA” last revised 09/06/2021 revealed, “...Transfers to the Hospital: i. The Hospital shall not refuse to accept an appropriate transfer of an individual ... ii. Upon notification from a transferring physician ... the Hospital shall respond to the transferring hospital and transferring physician with the status of the transfer request and either accept or refuse the transfer ...” A review of Patient #1’s medical record revealed Patient #1 was a 24-year-old male who presented voluntarily (no referral from an outside facility) to Hospital B on 02/24/2025 at 8:24 PM for anxiety, depression, and suicidal ideation after having a conflict with family members. Patient #1 was transferred via van to Hospital A for inpatient admission on 02/25/2025 at 12:15 AM. Patient #1 was transported back via van to Hospital B on 02/25/2025 at 12:47 AM after Hospital A stated that Patient #1 was not medically cleared for admission. Patient #1 was subsequently admitted voluntarily to a different inpatient psychiatric hospital on 02/25/2025 at 9:11 AM. A review of the medical record from Hospital B (sending facility) revealed, “HPI (History of Present Illness) on 02/25/2025 at 12:56 AM by Psychiatrist J: “...Patient was accepted at [Hospital A] and subsequently transferred there but for some reason, he was sent back with the [van driver]. Apparently there was some request of ‘medical clearance’ for unclear reasons. The writer received no communication in this regard...” A review of Hospital A’s (receiving facility) “BH Division Incident Report” filed on 02/25/2025 at 12:23 AM by Intake Coordinator M revealed, “Incident Type: EMTALA:...” -“Referral was received at 2207 (10:07 PM) and I [Intake Coordinator M] began reviewing it at 2208 (10:08 PM). -I called unit and sent text to House Sup (supervisor) at 2239 (10:39 PM) letting them know we would be accepting pt (patient). -I spoke with [Hospital B] and confirmed pt’s health status at 2245 (10:45 PM) as I noticed the referral stated he had not been medically cleared. Per [Hospital B’s RN (Registered Nurse) K], pt was in fact not medically cleared and was still presenting with similar symptoms (incl. (including) Productive cough, trouble breathing). I let [Hospital B’s RN K] know I would staff [sic] with [Psychiatrist G] and get back to him. -I called [Psychiatrist G] at 2248 (10:48 PM) and gave him all the above updates. [Psychiatrist G] stated the pt would need to be medically cleared before coming to us d/t (due to) his symptoms. -I called [RN K] from [Hospital B] at 2252 (10:52 PM) and let him know the pt would need medical clearance before admitting with us. [Hospital B’s RN K] acknowledged understanding and said he would ‘work on it.’ -I called house sup at 2256 (10:56 PM) from the intake cell to let her know all of the above updates and that [Patient #1] would no longer be needing N2N (nurse to nurse), as we are awaiting medical clearance. -Pt arrived here by van from [Hospital B] at 1:49 [sic]. -Van driver was informed by me that pt had not been medically cleared and we would alert house sup so that she could give us a directive. Van driver stated that he would call [Hospital B] in the meantime. -When house sup made it to intake (shortly after), the van driver had left and was no longer in the ambulance entrance. -From there, there was a myriad of phone calls between our staff and the staff at [Hospital B]. They stated they did not know pt needed medical clearance and also stated we turned the pt away ...” Observation of the security footage of Hospital A’s ambulance sally port and Intake Area revealed: 02/25/2025 at 12:23 AM: Van from Hospital B pulls up to the ambulance port and waits outside the gate. 02/25/2025 at 12:24 AM: Van driver from Hospital B rings bell outside of the ambulance port (no audio). 02/25/2025 at 12:31 AM: Van from Hospital B backs up and leaves Hospital A. 02/25/2025 at 12:49 AM: House Supervisor H attempts to go out to the ambulance sally port entrance. During an interview on 03/11/2025 at 11:24 AM with Director of Risk B, when asked about the incident with Patient #1, Director of Risk B stated, “I believe that this was a miscommunication issue. We attempted to go out to assess the patient, but they had already left. We understand that we need to evaluate our patients when they come to us.” During an interview on 03/12/2025 at 1:06 PM with Hospital B’s Driver L, when asked about Patient #1, Driver L stated, “We arrived at [Hospital A] and spoke with someone over the buzzer. We got told that the patient was not medically cleared, and they could not accept the patient. We took him back to [Hospital B], and [Hospital B] took the patient back from us.” An interview was conducted on 03/13/2025 at 8:19 AM with Hospital B’s Psychiatrist J. When asked about Patient #1, Psychiatrist J stated, “We don’t do a direct to doctor report. We talk to the intake department. The patient was reviewed by the intake department at [Hospital A]. I was told that [Patient #1] was accepted at [Hospital A]. He was medically stable when I evaluated him and from my understanding he was accepted at [Hospital A].””

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 29972 Based on observation, record review and interview the facility staff failed to ensure the physical environment was maintained in a safe manner to ensure the well being of patients in 3 of 3 patient units observed (Unit 1, Unit 2, Unit 5); and failed to follow policy and procedure to mitigate the risk of a potential bed bug infestation in 1 of 3 patient units (Unit 2), in a total sample of 3 units observed. Findings Include: The facility staff failed to ensure the physical environment was maintained in a safe manner to ensure the well being of patients. See Tag A-701. The facility staff failed to follow policy and procedure to mitigate the risk of a potential bed bug infestation. See Tag A-701.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 29972 Based on observation, record review and interview the facility staff failed to ensure the physical environment was maintained in a safe manner to ensure the well being of patients in 3 of 3 patient units observed (Unit 1, Unit 2, Unit 5); and failed to follow policy and procedure to mitigate the risk of a potential bed bug infestation in 1 of 3 patient units (Unit 2), in a total sample of 3 units observed. Findings Include: Review of policy and procedure #16533606 titled, “Bed Bugs” effective 02/06/2024 revealed the following: - Preventative: “Upon admittance, patients will be required to put on paper scrubs. Their belongings will then be placed in plastic bags. Clothing will be washed, and dried on the highest possible setting...” - “The following procedures are to be implemented immediately upon the detection or concern of a bed bug infestation: These steps must be performed as posted and in a timely manner to avoid a major infestation. 1. Infection control and Plant Ops (operations) should be contacted immediately at the first signs of the presence of bed bugs...2. All patients occupying the same bedroom must return to their room and remove all clothing and be provided paper scrubs. All clothing...should be placed in a water soluble bag and placed directly into a washing machine. The water should be set at the highest temperature available...once washed, clothes go directly into the dryer and again, be at its highest setting...4. All furniture should remain in the room to be treated...Mattresses should be disinfected...Pillows should be thrown away. 5. Housekeeping services should be contacted so room can be cleaned...All furniture cracks and crevices should be vacuumed...All interiors of dressers and wardrobes should be vacuumed...Vacuum should be brought directly outside of hospital, the vacuum bag should be placed in a plastic bag and be properly disposed of directly into the trash dumpster. 6. Room should be locked and appropriate signage placed on door. ‘Room out of service, Plant Ops/Housekeeping staff only to enter.’ 7. Plant Ops/Housekeeping staff will use a steam machine...8. Contracted Pesticide Company to be notified to come in and chemically treat room and furniture. 9. Plant operations and Infection Control Preventionist will check the room on a daily basis and determine when the room is ready to re-occupy...10. Once room is clear to re-occupy the housekeeping department will conduct a terminal clean.” Review of policy and procedure #15104447 titled, “Environmental Cleaning” effective dated 08/31/2024 revealed the following: - “Final accountability for all aspects of cleanliness rests with Administration.” - “The Director of Facilities Management (Plant Ops) and the Department Directors are responsible for...ensuring national guidance on cleanliness and associated environment service initiatives are interpreted and implemented in conjunction with Infection Control and Environmental Services.” - “Environmental services staff are responsible for carrying out cleaning of the general environment...” - “All staff are responsible for ensuring high standards of cleanliness with regard to...environment of care...including, but not limited to...floors...should be visibly clean with no...dirt, debris, dust...” On 09/10/2024 beginning at 11:20 AM, while touring the hospital with Director of Risk B, observed the following environmental concerns: Unit 5: - Unoccupied “clean” rooms #2054, 2061, and 2060 contained accumulated dust, debris, and/or dead insects on the floor near the baseboards by the window, shelving unit, bed frame, and in the corners of the room. - In room #2061, the bathroom contained strands of hair in the sink and on the counter top. - On unit #1, 2, and 5, the floors of the “clean” storage and linen closets contained an accumulation of dust, debris, supplies, packaging material and/or dead insects. - On unit #5, observed a live insect crawling on the floor in the common hallway. Per interview with Director B at the time of the observations on 9/10/2024 beginning at 11:20 AM, Director B confirmed the findings and stated the floors should be clean. Per interview with Mental Health Technician (MHT) M on 09/10/2024 beginning at 11:40 AM, MHT M stated that room #2054, #2061, and #2060 were cleaned and “ready for new admit.” Per interview with Director of Plant Operations H on 09/10/2024 beginning at 4:00 PM, Director H stated that the expectation is that every room is inspected daily by housekeeping staff even if it is clean and unoccupied. Director H stated that storage and linen closets should be cleaned daily. Review of Pt #1’s medical record revealed Pt #1 was admitted to the behavioral health hospital Unit 2 on 08/01/2024 at 8:56 PM with Suicidal Ideations and a history of depression; Pt #1 was discharged on 08/07/2024 at 2:17 PM. Review of Registered Nurse (RN) I’s Daily Nursing Assessment Progress Note dated 08/02/2024 at 4:40 PM, revealed, “(Pt #1) denied any physical discomforts...on his clothing what appeared to be a bed bug was seen, (Pt #1) was asked to remove all his clothing and followed the protocol...(Pt #1’s) linen were removed, (Pt #1’s) roommates clothes [sic].” Review of Pt #3’s medical record revealed Pt #3 was admitted to the behavioral health hospital Unit 2 on 07/31/2024 at 6:00 PM for Suicidal Ideations. On 08/03/2024 (no time) Pt #3 was discharged against medical advice after a “Request For Discharge” (no reason for request was documented). Review of patient list titled “Patient Visits Active in 08/02/2024...to 08/11/2024...” provided by staff revealed, Pt #3 was Pt #1’s roommate on 08/02/2024 from admission on 07/31/2024 at 8:31 AM to discharge on 08/03/2024 at 8:31 PM. Per interview with Director B on 09/11/2024 beginning at 12:53 PM, Director B was unable to confirm the exact room location of the patients each day and stated that the medical records documentation was “unclear” and does not show when patients are moved to different rooms. Per interview with MHT D on 09/11/2024 beginning at 1:23 PM, MHT D stated that she/he found the bed bug on Pt #1’s shoulder while Pt #1 was in the hallway of Unit 2 on 08/02/2024. MHT D stated that she/he escorted Pt #1 to the Exam room on Unit 2 and Pt #1 removed clothing in the Exam room (per policy this should be done in the patients room) and donned green paper scrubs; MHT D stated that she/he placed Pt #1’s cloths in a blue bag (not water soluble) and left the bag in the Exam room. MHT D stated that she/he did not ensure Pt #1 showered as per policy. MHT D stated that Pt #1 “probably” had a roommate and “probably was still in the room.” MHT D stated that a sign was not placed on Pt #1’s door as per policy (Room out of service, Plant Ops/Housekeeping staff only to enter); MHT D stated that the room was not immediately blocked off as per policy. Per MHT D, the room was not blocked off between Friday 08/02/2024 and Monday 08/05/2024. Per MHT D, the bedbug was shown to and confirmed with a nurse and then placed in a red specimen bag and thrown away. MHT D stated that she/he was not trained on how to handle bed bugs and was trying to “Google” what to do. MHT D stated that she/he was not aware that the patient’s clothing needed to go in a “water soluble” bag as per policy and MHT D was not aware of the process for washing clothes when addressing a potential bed bug infestation. Per interview with the Assistant Director of Nursing (ADON) J on 09/11/2024 beginning at 12:08 PM, ADON J stated that Pt #1 was identified with a bed bug on Friday 08/02/2024. ADON J stated that she/he directed staff to place Pt #1 and roommate (Pt #3) in a different room but ADON J stated that she/he found out later this did not happen. ADON J stated, “My recollection is that one patient was left in that room,” Per ADON J, she/he was told by staff on Monday 08/05/2024 that Pt #1 was moved out, but the roommate (Pt #3) was left in the room (until request for discharge on Saturday 08/03/2024). ADON J stated that she/he could not confirm if Patients (Pt #1 & Pt #3) showered. ADON J stated patients were not placed on contact precautions as per policy. ADON J stated that she/he does not remember if Infection Preventionist and Maintenance were contacted, but stated, “We usually do.” Per interview with Housekeeper N on 09/10/2024 beginning at 1:20 PM, Housekeeper N stated that rooms with potential bed bug infestation are “blocked...I don’t go in them.” Housekeeper N stated that pest control sprays first and then when given the ok, housekeeping staff will complete a terminal cleaning (this is inconsistent with the Bed Bug policy which revealed that Housekeeping staff should be contacted to clean the room as per policy). Per interview with Director of Plant Operations H on 09/10/2024 beginning at 4:00 PM, Director H stated he/she was not made aware of the bed bug incident until 08/04/2024 Sunday night (2 days after bed bug found) via a phone call from Housekeeping staff. Director H stated that the Pest Control company came to chemically treat the unit on Monday 08/05/2024 (3 days after incident). Director H stated that this was the only time he/she was made aware of a bed bug sighting. Director H stated that staff should notify Maintenance immediately after finding a bed bug. Director H stated that pest control treats the room first and then Housekeeping staff go into a room to terminally clean; per Director H, Housekeeping staff are not allowed in the room until cleared by the Pest Control company (this is inconsistent with the Bed bug policy which revealed the Housekeeping staff should be contacted to clean the room). Director H stated that he/she did not know if the Infection Preventionist was involved in this incident; Director H stated that he/she gave the ok to release the room and the Infection Preventionist was not involved in that decision as per the Bed Bug policy requires. Per interview with Infection Preventionist (IP) G on 09/10/2024 beginning at 3:33 PM, IP G was hired as a Nurse Educator and officially transitioned to the Infection Preventionist approximately 2 weeks ago. IP G stated that he/she was not aware of the incident involving bed bugs and was not aware of any increased monitoring or education occurring as a result of the bed bug incident. IP G stated that if a patient is found or suspected of having bed bugs, the room should be cleaned immediately, patients (including roommate) items put in a special bag to wash clothes, patients showered and given scrubs immediately and terminal cleaning to the Exam room. When asked who determines if the room is ready for a patient admission after the pest control is completed, IP G responded, “I would assume, if the pest company says it’s ready, it’s ready.” Per Bed Bug policy Plant Operations and Infection Preventionist must do daily checks and determine if a room is ready to re-occupy. Review of the Pest Control “Proof of Service” form revealed Bed Bug Sensitive Treatment was provided at the facility on 08/05/2024 at 4:04 PM (3 days after initial bed bug sighting). Per interview with Director of Risk B on 09/11/2024 beginning at 12:53 PM; Director B confirmed that Infection Preventionist G was the IP for the last 5 months. Director B stated that Director B was made aware of the bed bug sighting on 08/02/2024 and administration discussed a plan to address Pt #1 and roommate. When asked about the plan implemented by administration in response to the bed bug incident, Director B was unable to recall the details and specifics. Director B stated that staff should have notified Infection Preventionist and Maintenance immediately. Director B was unable to show that Pt #1’s roommate (Pt #3) was moved out of room. Director B stated that the Bed Bug policy was revised (09/10/2024) in response to this incident, however staff have not been educated on the policy revisions. Per staff interviews there was no evidence that facility staff addressed the bed bug concern as per policy and procedure to mitigate the risk of a bed bug infestation within the facility.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 43264 Based on record review and interview, the facility failed to ensure signed informed consents for Psychoactive drugs/medications (used to treat mood, thoughts, behavior or perception) was obtained for 1 of 10 patients (Patient #1) in a sample of 10 records reviewed. Findings include: A review of facility policy, titled “Medication Administration-Guidelines”, dated 01/13/2022, revealed: “...Medications are only given with a Physician/APRN (advanced practice nurse) order...A signed consent for a new psychoactive drug is required, except given in an emergency. Each new psychoactive drug must have its own consent form. Consent must be obtained prior to giving medication, except if given in an emergency...” Patient (Pt.) #1 was a 16-year-old male voluntarily admitted on 09/25/2023 and discharged on 10/09/2023, his Mom was his legal guardian to give/sign consents throughout his hospitalization. A review of Pt. #1’s “Medication Administration Record”, dated 09/25/2023 at 11:06 PM - 10/09/2023 at 12:28 PM, revealed a new Psychoactive medication, Wellbutrin XL 150 mg oral once a day for depression, was ordered on 10/05/2023 at 1:05 AM by Psychiatrist L - with first dose administered on 10/05/2023 at 9:00 AM. During an interview on 11/29/2023 at 2:23 PM, Director of Medical Records J confirmed that all medication consents for Pt. #1 were printed; there was no medication consent for Wellbutrin XL 150 mg daily prior to medication administration - per facility policy.”