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Based on observation, interview, and record review, the facility failed to protect and promote the rights of all patients on the behavioral health unit, resulting in the potential for unsatisfactory outcomes.

See Tags:
A0130 - Participation in Care Planning
A0131 - Right to make informed decisions
A0144 - Right to care in a Safe Setting
A0145 - Right to be free from Abuse/Harassment

Based on interview and record review, the facility failed to follow policy for the plan of care for 1 (P-2) of 10 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include:

P-2 is a 66-year-old male with a past medical history of hypertension, type 2 diabetes mellitus, lung cancer, and paranoid schizophrenia. He was brought to the emergency department on petition for agitation, confusion, and a direct threat to self. He was admitted to the facility on 11/2/25.

During record review, it was noted that the master treatment plan included behavioral health. The plan failed to include diabetes, blood glucose monitoring, or insulin use.

This finding was reviewed and acknowledged by the RN Coordinator (Staff G) during interview on 11/13/25 at 1415.

Policy 2PC 202: Nursing Plan of Care (effective date 3/16/25). The RN individualizes the pre-formatted plans of care to be reflective of the patient's condition.

Based on interview and record review, the facility failed to provide the patient with the right to make informed decisions regarding care in 1 (P-5) of 10 records reviewed, resulting in the potential for unmet care needs. Findings include:

P-5: This 40-year-old female has a prior history of schizophrenia and was voluntarily admitted to the facility on 11/4/25. P-5 was ordered and given Haldol 5mg twice daily, and Ativan 1mg at night.

During record review, it was noted that the general consent for admission and treatment was not signed by the patient. It was also noted that the chart failed to include psychotropic medication consents.

This finding was reviewed and acknowledged by the RN Coordinator (Staff G) during interview on 11/13/25 at 1415.

Patient Rights and Responsibilities (dated August 2019): To receive adequate and appropriate care, and to receive from the appropriate individual within the health facility or agency, information about your medical condition, proposed course of treatment and prospects for recovery, in terms you can understand unless medically contracted as documented by the attending physician in the medical record. To refuse treatment to the extent provided by law and to be informed of the consequences of that refusal.

Policy PMH 047: Use of Psychotropic Medications/Medication Procedures (Effective 2/20/2024). The indication for the initiation of the use of psychotropic medication will be noted in the clinical record with additional documentation which includes the following ...informed consent.

Based on observation, interview, and record review, the facility failed to label and monitor supplies used on patients, resulting in the increased likelihood of negative outcomes for all patients on the behavioral health unit. Findings include:

During unit tour on 11/12/25 at 1210, on 5 South Behavioral Health Unit, in the medication room, the blood glucose monitoring system control solutions were observed with an expiration date of 8/2026 but failed to include an opened date. RN (Staff P) was queried if control solutions should be dated when opened and responded they are supposed to be dated.

Policy 2POC PC 205-Blood Glucose Monitoring System Inform II (Effective 9/28/25). Storage and Handling: Glucose Control solutions are stable for three months after opening or until the expiration date, whichever comes first. The open date and expiration date must be recorded on the vials.


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On 11/12/2025 at 1210, during observation of the medication cupboard in the medication room on the behavioral health unit, three multiple dose vials of medications (Fluphenazine Decanoate, 125 milligram (mg) /5 mL, 5 mL Multiple Dose Vial x 2, Fluphenazine Hydrochloride 2.5 mg per mL, 10 mL Multiple Dose Vial x 1) were opened and punctured and there were no beyond use dates (BUD) noted on each of the three opened vials. One single dose vial of Sterile Water for Injection was observed with a puncture in the rubber stopper and stored on the shelf next to the multiple dose vials of injectable medications. Nurse Staff G confirmed the findings at the time of discovery.

On 11/12/2025 at 1220, during observation of the clean supply room in the behavioral health unit, sixteen blood collection tubes used for type and screen blood collection were observed in the supply drawer and were expired. Seven collection tubes had an expiration date of 10/1/2025 and 9 collection tubes had an expiration date of 5/1/2024. Nurse Staff G confirmed the findings at the time of discovery.

According to the facility's policy, "Multi-Use Containers and Medication Packaging Available in Patient Care Areas," dated 5/5/2024, The (Accreditation Body) requires that once a multi-dose pen or container of a medication for intravenous, intramuscular, subcutaneous, or intradermal injection is opened or puncture, organizations label the vials with a BUD (Beyond Use Date), as defined by the manufacturer or 28 days if no in use time is defined by the manufacturer."

The policy also reveals that "Single-dose/single use containers are only used for a single patent during the course of a single procedure. Discard the container after this single use; used containers should never be returned to stock or clinical units, drug carts, anesthesia carts, etc."

A policy was requested for the process to ensure expired medical supplies were removed from patient care areas, and the policy was not provided.

Based on observation, interview, and record review, the facility failed to accurately reflect the patient's safety precautions in the medical record for 2 (P-2, P-4) of 10 patients reviewed resulting in the increased likelihood of negative consequences for these patient. Findings include:

P-4 was admitted to the facility on 11/6/2025 with a diagnosis of schizophrenia spectrum and other related disorders. P-4 nursing's note on 11/7/2205 at 2130 revealed "Patient sexually preoccupied with (their) (opposite sex) peers, patient trying to dress provocative, sitting in room with just panties covering (their) breast and wearing a pair of panties, and dancing in front of (opposite sex) peers (doing the stanky (sic) leg) patient re-directed and placed on sexual precautions."

On 11/7/2025 at 2346, P-4 had an order for "Sexual Precautions" and the order also had a stop date of 11/7/2025 at 2346.

On 11/08/2025 at 1137, P-4's physician progress note revealed "Per staff, patient sexually preoccupied with her male peers, trying to dress provocative sitting in room with just panties covering her breast and wearing a pair of panties and dancing in front of male peers, staff had to redirect patient several times, (they) was placed on sexual precautions. Discourage such behavior."

On 11/9/2025 at 2020, P-4's physician progress note revealed "On sexual precautions."

P-4's patient observation sheets on 11/7/2025, 11/8/2025, 11/9/2025, and 11/10/2025 (1200-2345), and 11/13/2025 did not have sexually acting out precautions checked. The facility daily census sheet used to communicate patient information including safety precautions each day revealed that P-4 did not have sexually acting out precautions noted on 11/8/2025, 11/9/2025, and 11/12/2025. Nurse Staff H confirmed the findings at the time of discovery.







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P-2 is a 66-year-old male with a past medical history of hypertension, type 2 diabetes mellitus, lung cancer, and paranoid schizophrenia. P-2 was brought to the emergency department on petition for agitation, confusion, and a direct threat to self and was admitted to the facility on 11/2/25.

During record review on 11/13/25, it was noted that the safety precautions added on 11/1/25 at 1505 included elopement, homicide, and suicide. A progress note, completed by a mental health associate (MHA), dated 11/4/25, stated, "keeps reaching out to touch female staff/peers, gets upset easily when redirected." On 11/7/25 at 0108, a nursing note indicated P-2 was placed on sexual precautions after an incident of genital exposure and agitation/aggression.

The following The MHA frequent observation records indicated 15-minute checks and the following selected precautions:
11/2/25-no precautions selected
11/3/25-safety precautions
11/4/25-elopement precautions
11/5/25-no precautions selected
11/6/25-elopement precautions
11/7/25 & 11/8/25-safety precautions
11/9/25-elopement precautions
11/10/25 & 11/11/25-elopement and sexual precautions
11/12/25-elopement and safety precautions

This finding was reviewed and acknowledged by the RN Coordinator (Staff G), who stated sexual precautions should have been started immediately, during an interview on 11/13/25 at 1415.

According to the facility's policy, "Precautions: Monitoring and Reporting," (dated 7/12/2024), states "A patient may be placed on sexual precautions if there is a history or exhibit behaviors that are sexually inappropriate. The patient may be restricted from areas on the unit, be asked to remain in sight when not in a structure group. Or be placed on 1:1."

According to the facility's policy "Sexual Incidents Between Patients: Guidelines and Reporting," (dated 7/14/2024), states "1. Patients will be identified in the initial and ongoing psychiatric, social work, and/or nursing assessments if they are sexually dis-inhibited, have a history of sexual acting out, or are otherwise particularly vulnerable or aggressive. 2. Sexual precautions are instituted to alert staff to the possibility of sexual acting out."