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Based on record reviews and interview, it was determined the facility failed to meet the condition of participation for patient rights, when it failed to protect and promote each patient's rights as evidenced by,

1.) The facility staff did not follow the facility policy for patients requesting to leave when voluntary/involuntary patients were not assisted with filling out the 4-hour request form ( for Patient #10) or a physician was not asked to reexamine involuntary patients, possibly resulting in unreasonable confinement for Patient's #3, # 4, # 5, and #11; and,

2.) A voluntary patient reported being threatened with a threat of court action if they requested to leave, resulting in an unreasonable confinement for Patient #10.

Refer to A0129 for evidence.

Palms Behavioral failed to meet the conditions of participation under Physical Environment. when patient bedrooms and bathrooms were not constructed and maintained to ensure the safety of the patients; this failure resulted in patients being allowed to walk in standing puddles of water in the bathrooms, placing them at a high risk for slips and falls, and being exposed to untested accumulated black growth on the patient rooms air vents, placing them at risk for respiratory infections.

Refer to A0701

Based on interview and record review the facility failed to ensure that the exercise of patients' rights requirements are met when,

A.) The facility staff did not follow the facility's policy for involuntary patients requesting to leave when a physician was not asked to reexamine patients under emergency detention orders, for Patient's #3, #4, #5 and #11;

B.) A voluntary patient reported being threatened with a threat of court action if they requested to leave, resulting in an unreasonable confinement for Patient #10.

Findings include:

A.) Review of the facility provided policy, "Patient Rights", (undated) reflected, "Voluntary Patient - Special Rights 1. "You have the right to request discharge from the hospital. If you want to leave, you need to say so in writing or tell a staff person. If you tell a staff person you want to leave the staff person must write it down for you ... Involuntary patients - Special rights Under most circumstances, you or a person who has your permission may, at any time during your commitment, ask the court to ask a physician to reexamine you to determine whether you still meet criteria for commitment."

Review of the facility provided complaint logs contained Patient's #3, #4, #5, and #11's complaints with Staff #11, the Patient Liaison's, response to their complaint's as follows:

Patient #3- admitted on 4/5/25 under an emergency detention order, on 4/8/2025 reported, "He doesn't know why he is still here, explained OPC [order of protective custody] process."

Patient #4-admitted on 4/22/25 under an emergency detention order, on 4/30/25 reported, "Pt wants for me to discharge him, explained to pt that I do not discharge patients."

Patient #5- admitted on 8/23/25 under an emergency detention order, on 8/28/25 reported, "Pt called me and stated that he was told by the judge to call me to discharge him, informed pt that I do not discharge patients ..."

Patient #11- admitted prior to 7/3/25 on an emergency detention date, reported, "Pt asked me if I could discharge him, informed pt that I do not discharge patients, informed patient of his projected DC date."

During an interview on 9/11/25, Staff 11, Patient liaison, was asked if he assists the patients to fill out the Against Medical Advice (AMA) form, Staff 11 # stated, "No. I explain the 4-hour letter. I check if they are voluntary, I just go from there, the options that can come about. I tend to document whenever I speak to a patient."

During a telephone interview, on 9/12/25, when asked about the facility liaison responding to complaints of wanting to be discharged Staff #6, Compliance officer stated, "I have already started re-education of staffs, 'I don't discharge' responses should be, let me get your nurse."

B.) Review of the facility provided policy, "Patient Rights", (undated) reflected, "Voluntary Patient - Special Rights
1. You have the right to request discharge from the hospital. If you want to leave, you need to say so in writing or tell a staff person. If you tell a staff person you want to leave the staff person must write it down for you.
2. You have the right to be discharged from the hospital within four hours of requesting discharge. There are only 3 reasons why you would not be allowed to go:
a. First, if you change your mind ...
b. Second, if you are under 16 years old, and person who admitted you doesn't want you to leave
c. Third, you may ben[sic] detained longer than four hours inf[sic] your doctor has reason to believe that you ...
i. You are likely to cause serious harm to yourself
ii. You are likely to cause serious harm to others
iii. Your condition will continue to deteriorate, and you are unable to make an informed decision as to whether or not to stay for treatment. Even if a court order is filed, you cannot be detained at the hospital beyond 4:00 pm of the first business day following the in-person examination unless that a court-order for services is obtained.

Review of Patient #10's Physician's admission orders dated 8/17/2025 at 6:00 pm reflected, Legal Status Voluntary.

Review of the facility provided complaint logs contained Patient #10's complaint with Staff #11, the Patient Liaison's, response to their complaint as follow:
8/21/25: "Pt wanted to leave already, and wanted to know why she is here still, House Supervisors met and spoke with pt."

Review of the facility provided complaint log reflected 8/21/22, "Pt (Patient #10) wanted to leave already, and wanted to know why she is here still. House supervisors met and spoke with pt."

During a telephone interview on 9/11/25 at 11:15 am, when asked about her complaint, Patient #10 confirmed she had come in voluntarily and stated, "I was there a few days. I told the nurses I was ready to go home, I wanted to leave. The facility threatened me; I was told I would have to go to court and could stay here 30 more days if I said I wanted to go home." When asked who told her this Patient #10 stated, "Staff #11, and some nurses, I don't remember their names. I kept going to the nurse's station, telling them I had rights, they kept me here two more days."

Review of Patient #10's Physician's Discharge summary reflected the following:

On 8/21/2025 and 8/22/2025: "Patient reports depression at 0/10, anxiety 0/10, with 10 being worse. Patient denies s/h (suicidal/homicidal) ideations, no self-injurious behaviors. Denies mood swings, irritability, or aggression. Denies cravings for ETOH (alcohol) or illicit drugs. Denies both auditory and visual hallucinations, no delusional comments expressed. Patient reports eating well, showering daily, sleeping well. Patient is casually dressed, casual, AAOX4 (alert and oriented times four). Claims to be medication compliant and denies side effects at this time. Motivated to discharge as she wishes to return to work by Saturday. Per nursing, medication compliant, no aggression, anxiety/depression, interacting well with peers.

On 8/23/25: Patient is feeling good today. Okay sleep and appetite. Little bit sad. No suicidal or homicidal ideation. No auditory visual hallucination.

08/24/25 Patient is feeling good. sleep and appetite. No suicidal or homicidal ideation. No auditory visual hallucination. Med compliant ...

On 8/25/25: "Good." Patient reports depression at 0/10, anxiety 0/10, with 10 being worse. Patient denies s/h ideations, no self-injurious behaviors. Continues to voice readiness for discharge. Per nursing, Denies all, medication compliant, no aggression."

During a review of patient #10's medical records, when asked about the request to leave, Staff #2, RN stated, "I don't see the house supervisor's discussion. I don't see a formal request to discharge, only a talk about out-patient services." When asked why Patient #10 was not discharged, per her request, Staff #2 stated, "The provider will determine if the patient is ready to be discharged." The records did not indicate the provider was informed the patient was wanting to go home.

Based on observation, interview and record review the facility failed to develop and maintain the hospital environment to ensure the safety and wellbeing of the patients, when patients were being allowed to walk in standing puddles of water in the bathrooms, being exposed to untested accumulated black growth on the patient's bedroom air vents, and shower stalls being left with dark brown substances around the edges and seams.
Findings include:

Review of the facility provided "POLICY AND PROCEDURE: 800.904 Routine Cleaning Procedures" (Revised 2/23) reflected,
"N. PATIENT ROOMS
DAILY: ...Spot clean walls, doors, door facings, columns, and other building surfaces to remove handprints, smudges, and other obvious soil. Use a cloth and germicidal detergent solution from a spray bottle ...Clean basins and sinks. Use a disposable cloth, abrasive pad, lotion cleanser, and a spray bottle of germicidal detergent solution to remove soil from wash basins, sinks, shelves, and adjacent wall and partition surfaces.
Damp mop non carpeted floors. Use a well wrung mop and germicidal detergent solution. Place "Caution Wet Floor" signs around the area until the floor has dried.
Remove stains from carpet. Use a spray bottle of carpet shampoo solution, absorbent disposable cloths, and a utility brush. Consult your supervisor if the stain is not completely removed.
3. Clean patient rest rooms in accordance with the patient rest room cleaning procedures.
4. It is extremely important that patients be not unduly disturbed during the cleaning of the room. Judgment must be exercised in cleaning around a patient's bed while it is occupied. If uncertainty exists about cleaning around the patient, ask your supervisor for clarification.
5. If the patient is being attended or examined by medical staff, move to the next area and return later.
P. PATIENT REST ROOMS
DAILY:
Damp mop non carpeted floors. Place "Caution Wet Floor" signs around the area until the floor has dried. Use a well wrung mop and germicidal detergent solution. Use a deck brush or corner brush to remove and prevent buildup in corners, underneath toilets, etc.
Q. BATH, SHOWERS, AND BATHTUBS
DAILY:
Clean tubs. Use a disposable cloth. abrasive pad, lotion cleaner, and a spray bottle of germicidal detergent solution to remove soil from shelves and adjacent wall and partition surfaces. Dry bright metal surfaces to prevent water spotting. Wipe down walls with germicidal detergent solution and a clean cloth.
Flood the floor with a germicidal detergent solution and then mop. Scrub floors with a brush when needed. Flush afterward with clear water. Wet wipe curtains or change curtains as needed.

During a tour of the facility's in-patient units, on the morning of 9/8/25, accompanied by Staff #6, Compliance Officer the following findings were observed:

Room 311- the door was unlocked, and the patient was not in the room. Wads of toilet tissue, a 2 ft x 2 ft area, were piled up on the patient's exposed mattress; a shiny white liquid substance was lying pooled within the wadded tissues. A 4 ft x 4 ft carpeted area, leading into the room's bathroom, was soaked with standing water. The water pooled in the bathroom, around the commode and up to the shower stall, there was no barrier to prevent the water from coming out into the room, there was no shower curtain. The edge of the shower stall had a blackish-brown substance along the seams, including the stalls interior seam. The wall had signs of previous attempts to repair water damage to the sheetrock. There was no precaution wet floor sign to indicate the floor was wet.

Room 310- the door was open, and a patient was lying sleeping in the bed. Along the back wall an approximate area of 3 feet was spotted with a black splotchy substance growing on the wall. The shower stall had black debris along the seams between the shower and the flooring.

Room 302- The wall next to the commode was splattered with a brown substance and the floor had a dried yellow substance in the back corner and in the middle of the floor.

Room 308- The shower stall had black debris along the seams between the shower and the flooring. The bedrooms air vent had a dark brown substance on the grill.

Room 306- The bathroom door guard had a brown debris where patients would push the door open.

Room 402- The shower stall had black debris along the seams between the shower and the flooring. This room had a shower dam to prevent water from pooling on the floor; there was pooled water on the floor and the dam had blackish-brown debris on the jam. There was no precaution wet floor sign to indicate the floor was wet.

Room 404- There was a 4 ft x 3 ft of pooled water on the floor in front of the shower. There was no precaution wet floor sign to indicate the floor was wet.

Room 406- The patient's carpet had a large stain with a white edge around the stain, indicative of water having pooled onto the carpet. The seams around the commode were blackish-brown, and there was standing water in front of the shower. There was no precaution wet floor sign to indicate the floor was wet.

Room 405- The bathroom wall, next to the shower stall, had signs of water damage; the walls paint had bubbled out and been painted over. The shower stall had black debris along the seams between the shower and the flooring.

Room 601- The rooms air vent had copious amounts of splotchy black substance.

Room 508- The shower stall had black debris along the seams between the shower and the flooring. The wall next to the shower was bubbled up and had signs of past water damage repairs.

During an interview on the morning of 9/8/25, in patient room 311, Staff #4, housekeeper stated, "I had cleaned this room this morning. There was torn paper everywhere, the patient messed it up again. I am responsible for cleaning two units. I can't clean them when the patient is in the room. I do the best I can."

During an interview on the morning of 9/8/25, in patient room 311 When asked are the rooms cleaned daily, Staff #9, housekeeper stated, "I clean them when a patient leaves; I will clean the area where they sleep. I try to clean the restrooms; the nurses will call me if I need to clean one."

Review of the completed room cleanings dated 9/8/2025 reflected, Staff #4 vacuumed and shampooed room 306, cleaned half of rooms 305, 257, 311, 159, 327 and 504. Staff #9 cleaned room 206, and half of rooms 203, 207, and 211. The facility is certified for 94; the facility census was 87 on the day of the observations.

During an interview, in the administrative conference room, on the afternoon of 9/9/25, Staff #12, EOC (Environment of Care) Director stated in part that he was aware of the water draining into the bathrooms and patient rooms; this had been an issue that they had tried to fix by using an additional shower jam (room 402). The facilities staff remove the water and dry the carpets, when they are informed. There are two to three staff scheduled during the day, they are also responsible for cleaning the intake and administrative offices; there are no staff scheduled on nights and limited staff on the weekends."

Review of the current maintenance "Open and in Progress work orders", (undated) reflected the standing water for rooms 311, 402, 404, and 406 had not been identified and reported for clean-up and repair.

During an interview, on the morning of 9/9/25, in an administrative office, Staff #, CEO stated in part, the facility was in the process of removing the carpet from all the patient rooms and are replacing them with a material that can be cleaned; the facility had started in the intake area. The facility administration was aware of the pooling water in the bathrooms; water diversion thresholds had been placed in the handicapped shower stalls. The staff should be contacting the housekeeping to clean up any standing water.