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Based on review of records, observations, and interview, the Governing Body failed to effectively carry out its oversight responsibilities for ensuring patient rights were protected for 42 of 42 patients (Patients 1-31, 38-43, 47, 51-54). The Governing Body failed to ensure processes were developed with effective implementation of policies and procedures that provided patients with a safe, nonviolent environment. More specifically:

A) The facility failed to ensure an environment that protected and promoted the safety for 1 of 1 patient (Patient #32). This end-stage Alzheimer's patient, vulnerable to abuse by other patients because of his impaired memory, intrusive behavior, poor communication skills, and impaired judgment, was assaulted by other patients on four (4) occasions. He had an unwitnessed fall in his bedroom that resulted in a left wrist displacement and fracture to his left elbow and left iliac wing (hip). His level of observation was never increased from every 15-minute safety checks;

B) The facility failed to ensure that 7 of 31 patients (Patients 4, 13, 14, 20, 22, 23, and 29) admitted on suicide precautions were placed in environmentally safe rooms as evidenced by 24 of 24 bedrooms on the 100 and 200 units had observable ligature anchor points (the gap between the desk and wall created tie-off points). A sheet with a knot tied in one corner was wedged between the desk and the wall. In minutes, a suicidal patient could tie a knot in one corner of a piece of fabric, wedge the knot between the wall and the desk, and hang self;

C) The facility failed to ensure that 1 of 31 patient (Patient #14) admitted on suicide precautions was placed in an environmentally safe room as evidenced by a loose metal paper towel dispenser in the bathroom that created a ligature anchor point. A sheet was wedged between the edge of the dispenser and the wall. When staff pulled on the sheet, it stayed in place. A suicidal patient could wedge a piece of fabric on the top of the loose paper towel dispenser and hang self. In addition, 10 of 24 metal paper towel dispensers had sharp metal edges that could be used for self-mutilation. A patient engaged in "parasuicidal behaviors," such as cutting, could cut self on the sharp metal edges of the dispensers. The cumulative effects of self-mutilation can be lethal;

D) The facility failed to ensure that 7 of 31 patients (Patient 4, 13, 14, 20, 22, 23, and 29) admitted with suicidal ideation were placed in an environmentally safe room. 46 of 46 beds had fitted sheets. Each fitted sheet had a thick full-length band around the perimeter. When a sheet was wedged atop the metal paper towel dispenser, it began to rip, separating the band from the body of the sheet. A suicidal patient could rip the remainder of the band from the sheet and use the band for strangulation or hanging;

E) The facility failed to ensure that 4 of 4 patients (Patients 51, 52, 53, and 54) could be monitored safely in 2 of 2 seclusion rooms (rooms 034 and 035). The seclusion rooms had blind spots (one corner of the room and the floor space on the far side of the bed). When monitoring patients through the glass window of the seclusion room door, staff standing outside the seclusion room would not be able to see the actions of patients in the blind spots. Within minutes, a suicidal patient can suffer irreversible brain damage or kill self by strangulation;

F) The facility failed to ensure that 1 of 31 patients (Patient 31) was in a contraband-free bedroom (room 212). The cabinets and drawers in the anteroom of this negative pressure room were unlocked, giving the patient access to numerous contraband items (rubber gloves and other personal protective equipment, plastic trash liners, and numerous isolation supplies). A suicidal patient would have access to numerable items that could be used for strangulation or hanging;

G) The facility failed to ensure that staff members that developed the Environmental Risk Assessment identified all ligatures and ligature anchor points on the 100 and 200 units. This included 24 of 24 bedrooms with a gap between the desk and wall that created ligature anchor points, 5 of 24 bathrooms with loose metal paper towel dispensers that created ligature anchor points, 46 of 46 beds with fitted sheets that had a thick full-length band around the perimeter of the sheet that created ligatures; and bedroom 212 (the negative pressure room) with unlocked cabinets and drawers in the anteroom that provided patients with access to numerous contraband items (rubber gloves and other personal protective equipment, plastic trash liners, and numerous isolation supplies). This also included 10 of 24 recessed paper towel dispensers that had sharp metal edges that could be used for self-mutilation and 2 of 2 seclusion rooms with blind spots. The assessment is meant to be a proactive process to, at a minimum, identify self-harm issues prior to the patient being placed in the room. It is a thoughtful evaluation of the environment with a mitigation plan and available resources to guide staff when housing patients at risk for suicide or self-harm;

H) The facility failed to ensure that 2 of 3 housekeeping staff (Staff F and Staff I) had been properly trained in the security and positioning of 2 of 2 housekeeping carts while they were inside the bedroom cleaning. A locked housekeeping cart promotes a ligature resistant environment and prevents patients access to dangerous cleaning chemicals. Secured mops and brooms help prevent patients access to potentially harmful weapons;

I) The facility failed to ensure that 31 of 31 patients (Patients 1-31) were protected from potential abuse, neglect, and harassment. This failure resulted in 1 of 9 new hires (Staff F) being hired and placed on units 100 and 200 with very vulnerable psychiatric patients without first conducting a pre-employment background check. Background checks that include employment verification, criminal records check, and national sex offender check are essential in the protection of patients;

J) The facility failed to ensure that future patients within the community were safe from abuse, harassment, and sexual misconduct by 2 of 2 staff member (Staff OO and Staff PP). Though allegations of abuse, harassment, and sexual misconduct of these two CNAs were supported by video surveillance and witness accounts and they were terminated, the two CNAs were not reported to the CNA registry at Texas Health and Human Services by the facility, thus allowing them the opportunity to repeat this behavior at yet another behavioral health facility;

K) The facility failed to ensure that 1 of 1 patient (Patient #32) had a proper investigation following a fall in which the patient sustained several fractures;

L) The facility failed to ensure that the identify of 31 of 31 patients (Patients 1-31) remained confidential as evidenced by 31 of 31 patients had their full names on the spine of their medical records. In addition, 18 of 18 patients (Patients 1-18) had their full names on a white board mounted in the nurse's station, Failure to develop appropriate strategies to protect individual identifiers can result in a breach of patient confidentiality;

M) The facility failed to ensure that 31 of 31 patients (Patients 1-31) had access to an identified patient advocate to file a complaint or grievance, had contact information for the patient advocate that was readily available; had been given instructions on how to file a complaint or grievance, and had been provided with a complaint or grievance form; and

N) The facility failed to ensure that 7 of 9 patients (Patients 38-43) had been provided the prompt resolution of their grievances.

Cross reference CFR 482.13. A0115 - PATIENT RIGHTS.

Based on review of records, observations, and interview, the facility failed to ensure processes were developed with effective implementation of policies and procedures that protected and promoted the rights of 42 of 42 patients (Patients 1-31, 38-43, 47, 51-54). More specifically:

A) The facility failed to ensure an environment that protected and promoted the safety for 1 of 1 patient (Patient #32). This end-stage Alzheimer's patient, vulnerable to abuse by other patients because of his impaired memory, intrusive behavior, poor communication skills, and impaired judgment, was assaulted by other patients on four (4) occasions. He had an unwitnessed fall in his bedroom that resulted in a left wrist displacement and fracture to his left elbow and left iliac wing (hip). His level of observation was never increased from every 15-minute safety checks.

Cross reference CFR 482.13(c)(2). A0144 - PATIENT RIGHTS: CARE IN SAFE SETTING

B) The facility failed to ensure that 7 of 31 patients (Patients 4, 13, 14, 20, 22, 23, and 29) admitted on suicide precautions were placed in environmentally safe rooms as evidenced by 24 of 24 bedrooms on the 100 and 200 units had observable ligature anchor points (the gap between the desk and wall created tie-off points). A sheet with a knot tied in one corner was wedged between the desk and the wall. In minutes, a suicidal patient could tie a knot in one corner of a piece of fabric, wedge the knot between the wall and the desk, and hang self.

Dross reference CFR 482.13(c)(2). A0144 - PATIENT RIGHTS: CARE IN SAFE SETTING

C) The facility failed to ensure that 1 of 31 patient (Patient #14) admitted on suicide precautions was placed in an environmentally safe room as evidenced by a loose metal paper towel dispenser in the bathroom that created a ligature anchor point. A sheet was wedged between the edge of the dispenser and the wall. When staff pulled on the sheet, it stayed in place. A suicidal patient could wedge a piece of fabric on the top of the loose paper towel dispenser and hang self. In addition, 10 of 24 metal paper towel dispensers had sharp metal edges that could be used for self-mutilation. A patient engaged in "parasuicidal behaviors," such as cutting, could cut self on the sharp metal edges of the dispensers. The cumulative effects of self-mutilation can be lethal.

Cross reference CFR 482.13(c)(2). A0144 - PATIENT RIGHTS: CARE IN SAFE SETTING

D) The facility failed to ensure that 7 of 31 patients (Patient 4, 13, 14, 20, 22, 23, and 29) admitted with suicidal ideation were placed in an environmentally safe room. 46 of 46 beds had fitted sheets. Each fitted sheet had a thick full-length band around the perimeter. When a sheet was wedged atop the metal paper towel dispenser, it began to rip, separating the band from the body of the sheet. A suicidal patient could rip the remainder of the band from the sheet and use the band for strangulation or hanging.

Cross reference CFR 482.13(c)(2). A0144 - PATIENT RIGHTS: CARE IN SAFE SETTING

E) The facility failed to ensure that 4 of 4 patients (Patients 51, 52, 53, and 54) could be monitored safely in 2 of 2 seclusion rooms (rooms 034 and 035). The seclusion rooms had blind spots (one corner of the room and the floor space on the far side of the bed). When monitoring patients through the glass window of the seclusion room door, staff standing outside the seclusion room would not be able to see the actions of patients in the blind spots. Within minutes, a suicidal patient can suffer irreversible brain damage or kill self by strangulation.

Cross reference CFR 482.13(c)(2). A0144 - PATIENT RIGHTS: CARE IN SAFE SETTING

F) The facility failed to ensure that 1 of 31 patients (Patient 31) was in a contraband-free bedroom (room 212). The cabinets and drawers in the anteroom of this negative pressure room were unlocked, giving the patient access to numerous contraband items (rubber gloves and other personal protective equipment, plastic trash liners, and numerous isolation supplies). A suicidal patient would have access to numerable items that could be used for strangulation or hanging.

Cross reference CFR 482.13(c)(2). A0144 - PATIENT RIGHTS: CARE IN SAFE SETTING

G) The facility failed to ensure that staff members that developed the Environmental Risk Assessment identified all ligatures and ligature anchor points on the 100 and 200 units. This included 24 of 24 bedrooms with a gap between the desk and wall that created ligature anchor points, 5 of 24 bathrooms with loose metal paper towel dispensers that created ligature anchor points, 46 of 46 beds with fitted sheets that had a thick full-length band around the perimeter of the sheet that created ligatures; and bedroom 212 (the negative pressure room) with unlocked cabinets and drawers in the anteroom that provided patients with access to numerous contraband items (rubber gloves and other personal protective equipment, plastic trash liners, and numerous isolation supplies). This also included 10 of 24 recessed paper towel dispensers that had sharp metal edges that could be used for self-mutilation and 2 of 2 seclusion rooms with blind spots. The assessment is meant to be a proactive process to, at a minimum, identify self-harm issues prior to the patient being placed in the room. It is a thoughtful evaluation of the environment with a mitigation plan and available resources to guide staff when housing patients at risk for suicide or self-harm.

Cross reference CFR 482.13(c)(2). A0144 - PATIENT RIGHTS: CARE IN SAFE SETTING

H) The facility failed to ensure that 2 of 3 housekeeping staff (Staff F and Staff I) had been properly trained in the security and positioning of 2 of 2 housekeeping carts while they were inside the bedroom cleaning. A locked housekeeping cart promotes a ligature resistant environment and prevents patients access to dangerous cleaning chemicals. Secured mops and brooms help prevent patients access to potentially harmful weapons.

Cross reference CFR 482.13(c)(2). A0144 - PATIENT RIGHTS: CARE IN SAFE SETTING

I) The facility failed to ensure that 31 of 31 patients (Patients 1-31) were protected from potential abuse, neglect, and harassment. This failure resulted in 1 of 9 new hires (Staff F) being hired and placed on units 100 and 200 with very vulnerable psychiatric patients without first conducting a pre-employment background check. Background checks that include employment verification, criminal records check, and national sex offender check are essential in the protection of patients.

Cross reference CFR 482.13(c)(3). A0145 - PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT

J) The facility failed to ensure that future patients within the community were safe from abuse, harassment, and sexual misconduct by 2 of 2 staff member (Staff OO and Staff PP). Though allegations of abuse, harassment, and sexual misconduct of these two CNAs were supported by video surveillance and witness accounts and they were terminated, they were not reported to the CNA registry at Texas Health and Human Services by the facility, thus allowing them the opportunity to repeat this behavior at yet another behavioral health facility.

Cross reference CFR 482.13(c)(3). A0145 - PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT

K) The facility failed to ensure that 1 of 1 patient (Patient #32) had a proper investigation following a fall in which the patient sustained several fractures.

Cross reference CFR 482.13(c)(3). A0145 - PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT

L) The facility failed to ensure that the identify of 31 of 31 patients (Patients 1-31) remained confidential as evidenced by 31 of 31 patients had their full names on the spine of their medical records. In addition, 18 of 18 patients (Patients 1-18) had their full names on a white board mounted in the nurse's station, Failure to develop appropriate strategies to protect individual identifiers can result in a breach of patient confidentiality.

Cross reference CFR 482.13(d)(1). A0147 - PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS

M) The facility failed to ensure that 31 of 31 patients (Patients 1-31) had access to an identified patient advocate to file a complaint or grievance, had contact information for the patient advocate that was readily available; had been given instructions on how to file a complaint or grievance, and had been provided with a complaint or grievance form.

Cross reference CFR 482.13(a)(2). A0118 - PATIENT RIGHTS: GRIEVANCES

N) The facility failed to ensure that 7 of 9 patients (Patients 38-43) had been provided the prompt resolution of their grievances

Cross reference CFR 482.13(a)(2). A0118 - PATIENT RIGHTS: GRIEVANCES

Based on record review and interview, the facility failed to ensure 31 of 31 patients (Patients 1-31) had access to an identified patient advocate to file a complaint or grievance, had contact information for the patient advocate readily available; had been given instructions on how to file a complaint or grievance, and had been provided with a complaint or grievance form. In addition, the facility failed to ensure that the prompt resolution of patient grievances had been established for 6 of 9 patients (Patients 38-43).

Findings included:

Record review of the patient census for 12/7/2021 showed 31 patients.

Observation of units 100 and 200 during the initial tour on 12/7/2021 showed that the name and contact information for the Patient Advocate was not posted for patients to see.

In interviews with Staff B (DON) and Staff C (CCO) on 12/7/2021 at 2:30pm, they stated that there was not a patient advocate and no contact person assigned to investigate complaints filed by patients. They also stated that patients had not been informed whom to contact to file a grievance at the time of admission into the facility. They concluded by saying that information on the patient advocate was not posted on the unit and that patients and staff did not have access to a grievance form on which to file a complaint or grievance.

Record review of the 2021 Grievances Log showed 7 of 9 patients (Patients 38-43, 47) with grievances that were incomplete or not investigated or unresolved. They included:

Patient #38.
Notification date of complaint: 4/30/2021. Complaint closed on 5/14/2021. There was no additional information, investigation, resolution, disciplinary action, or action plan.

Patient #39.
Notification date of complaint: 4/30/2021; Complaint closed on 5/11/2021. There was no additional information, investigation, resolution, disciplinary action, or action plan.

Patient #40.
Notification date of complaint: 5/5/2021; Complaint closed on 5/14/2021. There was no additional information, investigation, resolution, disciplinary action, or action plan.

Patient #41.
Notification date of complaint: 5/7/2021; Complaint closed on 5/14/2021. There was no additional information, investigation, resolution, disciplinary action, or action plan.

Patient #42.
Notification date of complaint: 5/26/2021; Complaint closed on 6/28/2021. There was no additional information, investigation, resolution, disciplinary action, or action plan.

Patient #43.
Notification date of complaint: 8/26/2021; Complaint closed on 9/27/2021. There was no additional information, investigation, resolution, disciplinary action, or action plan.

Record review of Policy 10842480, "Patient Advocate," revised and approved 12/2021, showed: "PURPOSE: To provide guidance on patient advocate responsibilities to ensure patient rights issues are addressed and resolved according to policy.
"POLICY: ...
o Resolve complaints by patients that cannot be resolved at the point of service.
o Ensure significant patient complaints are brought to the attentions of appropriate staff to obtain further assistance to resolve the issue.
o Ensure patients and staff are aware of the complaint/grievance process and options that are available to assist patients and their families regarding unresolved complaints.
o Ensure ongoing communication with patients about their concern including final resolution."

Based on interview, record review, and observation:

A) The facility failed to ensure an environment for 1 of 1 patient (Patient #32) that protected and promoted his safety. This failure resulted in this end-stage Alzheimer's patient being assaulted numerous times by other patients and sustaining fractures as the result of an unwitnessed fall, with no initial level of observations ordered and no increase in the level of observations.

B) The facility failed to ensure that 7 of 31 patients (Patients 4, 13, 14, 20, 22, 23, and 29) admitted on suicide precautions were placed in environmentally safe rooms as evidenced by 24 of 24 bedrooms on the 100 and 200 units had observable ligature anchor points (the gap between the desk and wall created tie-off points);

C) The facility failed to ensure that 1 of 31 patient (Patient #14) admitted on suicide precautions was placed in an environmentally safe room as evidenced by a loose metal paper towel dispenser in the bathroom that created a ligature anchor point. In addition,10 of 24 metal paper towel dispensers had sharp metal edges that could be used for self-mutilation;

D) The facility failed to ensure that 7 of 31 patients (Patient 4, 13, 14, 20, 22, 23, and 29) admitted with suicidal ideation were placed in an environmentally safe room. 46 of 46 beds had fitted sheets. Each fitted sheet had a thick full-length band around the perimeter that could be removed and potentially used for strangulation or hanging;

E) The facility failed to ensure that 4 of 4 patients (Patients 51, 52, 53, and 54) could be monitored safely in 2 of 2 seclusion rooms (rooms 034 and 035). The seclusion rooms had blind spots;

F) The facility failed to ensure that 1 of 31 patients (Patient 31) was in a contraband-free bedroom (room 212) as evidenced by unlocked cabinets and drawers in the anteroom giving the patient access to numerous contraband items;

G) The facility failed to ensure that staff members that developed the Environmental Risk Assessment identified all ligatures and ligature anchor points on the 100 and 200 units as evidenced by: 24 of 24 bedrooms with a gap between the desk and wall, 5 of 24 bathrooms with loose metal paper towel dispensers, 46 of 46 beds with fitted sheets that had a thick full-length band around the perimeter, and bedroom 212 with unlocked cabinets and drawers in the anteroom that provided patients with access to numerous contraband items. This also included 10 of 24 recessed paper towel dispensers that had sharp metal edges and 2 of 2 seclusion rooms with blind spots;

H) The facility failed to ensure that 2 of 3 housekeeping staff (Staff F and Staff I) had been properly trained in the security and positioning of 2 of 2 housekeeping carts while they were inside the bedroom cleaning;


Findings included:

A) Patient #32 was not protected in the environment.

[Note: The evidence is in chronological order. The documented assaults that Patient #32 endured are found on 10/1/2021, 10/3/2021, 10/20/2021, and 11/1/2021. The fall that resulted in fractures occurred on 11/18/2021.]

Record review of the medical records of Patient #32 showed three admissions:

1. 9/20/2021 - 10/6/2021;
2. 10/12/2021 - 11/18/2021; and
3. 11/20/2021 - 11/24/2021.


1. First Admission: 9/20/2021 - 10/6/2021.

Record review of policy 9742509, "Patient Observation," revised 5/2021 showed:
"POLICY:
On admission, patients will be assigned an observation level. An order indicating the observation level shall be based on an assessment of the patient's emotional, physical, cognitive, and behavioral status as determined by the nursing personnel assessing the patient for admission wit specific consideration as to the risk posed to themselves others. Patients will continue to be assessed and monitored during their treatment to ensure observation levels are appropriate.
PROCEDURE:
1. On admission, the patients will be assessed for the level of observation. The provider will order the one of two observation levels."

Record review of the Psychiatric Evaluation by Staff KK (MD) dated 9/21/2021 at 11:12pm showed a 67-y/o male admitted from a nursing home with dementia and behavioral disturbances. He had hit another resident with his casted arm. He threatened staff and made racial slurs. He had a history of recurrent falls, muscle wasting and atrophy, recent fracture of lower right radius bone, and major neurocognitive disorder. He had mumbling speech, disorganized thought processes; memory grossly impaired; and impaired insight and judgment. Diagnostic impression: Major neurocognitive disorder, behavioral disturbances, insomnia, and rule out depression.

Record review of Admission Orders by Staff RR (NP) dated 9/20/2021 at 8:20pm showed Assault Precautions were ordered. There was no order for Fall Precautions. There was no order for neither 15-minute nor a one-on-one Nursing Observations.

Review of the History & Physical by Staff RR (NP) dated 9/21/2021 at 12:00pm showed the patient "very confused ... unable to answer questions." Impression/Plan: Recurrent falls. Fall Precautions.

Record review of Psychiatry Progress Note by Staff KK (MD) dated 9/22/2021 at 11:15am showed patient intrusive and disoriented. Defecating and urinating in other patient's rooms.

Record review of Internal Medicine Progress Note by Staff X (NP) dated 9/22/2021 at 3:01pm, 9/25/2021 at 1:18pm, 9/26/2021 at 11:58am, 9/27/2021 at 10:46am, 9/28/2021 at 11:38am and 9/29/2021 at 2:48pm showed patient sleeping in other patient's beds. Nonverbal.

Record review of Daily Nursing Narrative by Staff HH (LVN) dated 9/23/2021 at 11:00am, 9/27/2021 at 10:30am and 9/28/2021 at 10:00am showed patient wandered into other patient's rooms.

Record review of Daily Nursing Narrative by Staff R (RN) dated 9/27/2021 [no time] showed patient took other patients' food and water away from them.

=>=>=> First Documented Assault of Patient #32.
Record review of Daily Nursing Narrative by Staff SS (LVN) dated 10/1/2021 at 10:00am showed patient was in a room sleeping. Another patient came into the room and punched him in the face. Visible laceration on bridge of nose.

Record review of an Internal Medicine Progress Note by Staff X (NP) dated 10/2/2021 at 2:16pm showed: Patient #32 sleeping in wrong room. Agitated and combative with other patients. Another patient punched Patient #32 because he was sleeping in his room. Patient #32 sustained nosebleed. EMS evaluated. Patient combative with paramedics and refused to be transferred.

Review of an incident report by Staff SS (LVN) dated 10/6/2021 at 6:30pm showed the aggressive patient first attacked and bit a CNA, then attacked Patient #32.

=>=>=> Second Documented Assault of Patient #32.
Record review of an incident report by Staff HH (RN) dated 10/3/2021 at 1:40pm showed that Patient #21 was "physically aggressive" towards Patient #32. Patient #21 pushed Patient #32 into a housekeeping cart.

Record review of the Discharge Summary by Staff QQ (NP) dated 10/7/2021 at 9:54am showed the patient was discharged back to the nursing home. He had a posterior cortical atrophy type dementia that had affected his eyesight, hearing, and ability to judge distances, and the differences in moving or still objects, as well as depth of perception of chairs and objects. Discharge diagnoses: Major neurocognitive disorder with behavioral disturbances and insomnia due to mental ... condition.

2. Second Admission: 10/12/2021 - 11/18/2021.

Record review of Admission Orders dated 10/12/2021 showed Assault and Fall Precautions and Nursing Observations every 15 minutes.

Record review of the Psychiatric Evaluation by Staff KK (MD) dated 10/14/2021 at 12:15pm showed Patient #32 readmitted for increasing agitation and aggressive behavior. He had been wandering into female patient's rooms at the nursing home and hit two staff members. He had recurrent falls.
Diagnostic impression: Major neurocognitive disorder, unspecified, with behavioral disturbances; unspecified anxiety disorder; and unspecified depressive disorder.

Record review of the History & Physical by Staff X (NP) dated 10/13/2021 at 12:36pm showed the patient to be a "high fall risk" with a history of repeated falls and muscle wasting.

Record review of Psychiatry Progress Note by Staff QQ (NP) dated 10/14/2021 at 10:45am showed patient was impulsive, agitated, irritable, and intrusive with poor boundaries.

Record review of Psychiatry Progress Note by Staff QQ (NP) dated 10/15/2021 at 11:45am showed patient yelled at and hit multiple patients and staff, was "easily triggered," and disrobed on the unit.

Record review of Daily Nursing Narrative by Staff P (RN) dated 10/15/2021 at 11:00am and 3:30pm showed patient went into other patient's rooms, took other patient's food and beverages, and took a patient's coffee and spilled it on another patient.

=>=>=> Third Documented Assault of Patient #32.
Record review of Daily Nursing Narrative by Staff B (DON) dated 10/20/2021 at 8:20pm showed Patient #32 was "punched several times" by a peer and "fell to the floor." He had a red area and a black and blue area by his right eye. He was very upset and was taken to the quiet room.

Record review of Psychiatry Progress Note by Staff VV (NP) dated 11/1/2021 at 9:30am showed patient seclusive to room and intrusive. Sleeping in other patient's rooms.

=>=>=> Fourth Documented Assault of Patient #32.
Record review of Internal Medicine Progress Note dated 11/2/2021 showed that on 11/1/2021, patient "got punched in the left temple ... and had some altered level of consciousness following and was sent for a CT of the head and returned."

Record review of Observation Rounds dated 11/1/2021 1:00pm - 9:00pm showed the patient was transferred to another facility.

Review of the Incident Report Log showed that the assault on 11/1/2021 to Patient #32 was not captured on the log. In an interview with Staff C (CCO) on 12/9/2021 at 5:15pm, he stated that if the incident was not listed on the Incident Report Log, then there was no incident report.

In an interview with Staff WW (CNA) on 12/16/2021 at 10:25am, she stated that on 11/18/2021, she was providing one-on-one observation. She "heard a noise" that sounded "like someone hit the floor hard." This occurred "before breakfast, around 7:45am." She "peeked" into Patient #32's room and saw that he was on the floor. She summoned help. Patient #32 was put back into the bed by staff and "he didn't get back up." He was gotten up for lunch and "fell again and put in a wheelchair. His arm looked broken." She stated she did not hear anyone go into Patient #32's room just prior to the fall.

Record review of Daily Nursing Narrative by Staff B (CNO) dated 11/18/2021 at 12:00pm showed patient was on the "floor lying between beds. Complained of pain left elbow. X-ray here. Fracture to left elbow. Orders received to transfer per ambulance to [medical facility]. Family notified of fall and transfer to hospital."

Record review of Physician Orders by Staff X (NP) dated 11/18/2021 at 1:10pm showed an order for a STAT [immediate] x-ray of the left elbow. At 1:45 Staff X (NP) ordered a transfer out by ambulance for treatment of a left elbow fracture.

Record review of incident report by Staff P (RN) dated 11/18/2021 (no time) showed an order to send the patient out for medical treatment at 1:45pm. He was transferred at 2:28pm.

Record review of the medical record for Patient #32 showed that the Patient Safety Observation Round for 11/18/2021 was missing.

In an interview with Staff XX (Medical Records) on 12/16/2021 at 11:30am, she stated she could not find the Patient Safety Observation Round for 11/18/2021. In addition, Staff B (DON) and Staff C (CCO) stated they did not know the location of the missing round sheet.

3. Third Admission: 11/20/2021 - 11/24/2021.

Record review of Psychiatric Evaluation by Staff KK (MD) dated 11/28/2021 at 4:24pm showed that Patient #32 was readmitted on 11/20/2021 after being transferred to a medical center for treatment for treatment of a closed fracture olecranon process left arm sustained from a fall. Hospice care was discussed.

Record review of the Admission Orders by Staff KK (MD) dated 11/20/2021 at 2:46pm showed Assaultive and Fall Precautions. Nursing Observations (every 15 minutes vs. 1:1) were not ordered.

Record review of the Patient Safety Observation Rounds showed:
11/20/2021 - missing.
11/21/2021 - high risk for fall. One-on-one observations starting at 7:00am.
11/22/2021 - missing.
11/23/2021 - high risk for fall. One-on-one observations starting at 7:00am.
11/24/2021 - high risk for fall. No observation level indicated.

Record review of History & Physical by Staff X (NP) dated 11/20/2021 at 3:36pm showed the patient was found to have an acute closed fracture to the left elbow, acute closed fracture to the left hip, and mild displacement of the lift wrist, as well as an acute left iliac wing fracture.

Record review of Physician Orders by Staff KK (MD) dated 11/23/2021 at 3:00am showed: "1:1 sitter [for an] increase risk of falls" was written and then scratched out. "Floor mats for safety" was ordered.

Record review of Internal Medicine Progress Note by Staff RR (NP) dated 11/24/2021 at 12:37pm showed patient was discharged into hospice per family's request.

Record review of Discharge Summary by Staff KK (MD) dated 12/5/2021 at 10:57am showed patient was "debilitated," not eating or drinking, weak, and withdrawn.

Record review of the obituary for Patient #32 showed he passed on 11/25/2021. [This was the day after discharge from the facility.]


B, C, and D) Bedrooms and bathrooms with ligatures (fitted sheets) and ligature anchor points (desks and metal paper towel dispensers.

Review of policy 9929981, "Ligature and Ligature Anchor Points - Risk Assessment," revised and approved 1/2021, showed:
"DEFINITIONS:
Ligature - anything that could be used to bind or tie and potentially used for hanging/self-strangulation.
Ligature Anchor Point - any piece of equipment, furniture, fixture, etc., that could be used to attach a string, rope, cord, or other material with the intent of hanging or strangulation. Ligature anchor points may be above or below head height ...
POLCIY:
The facility's Safety/Environment of Care Committee shall be responsible for conducting environmental risk assessments and identifying the facility's possible ligatures and ligature anchor points. The Safety/Environment of Care Committee shall conduct environmental risk assessments annually.
The Safety/Environment of Care Committee shall be responsible for identifying and mitigating possible ligatures including ... bedding ... wall fixtures ..."

During rounds of units 100 and 200 on 12/7/2021 at 11:30am with Staff A (CEO), Staff C (Chief Clinical Officer), Staff K (Corporate Security), and Staff J (maintenance), it was observed that there was a one-inch gap between the desk and wall in all 24 of the patient bedrooms. A knot was tied at one corner of a fitted sheet. The knot was then wedged between the wall and the desk, creating a ligature risk. Staff C pulled on the fitted sheet and the knot held the sheet in place. He stated that the gap between the desk and the wall created a ligature anchor point.

Upon examination of the fitted sheet, it was observed that the fitted sheet had a thick full-length band all the way around the perimeter of the sheet. 46 of 46 beds had fitted sheets on them.

24 of 24 bathroom had metal paper towel dispensers mounted into the wall. 5 of the 24 dispensers of were loose and could easily be pulled out enough to create a tie-off point. Staff C and Staff J stated that these loose paper towel dispensers could be used as ligature anchor points. The band on the perimeter of a fitted sheet was used to secure the sheet to the top of the dispenser. Staff J pulled on the sheet and it held in place. He stated that the edge of the dispenser created a ligature anchor point. The sheet, just inside the thick full-length band, began to rip, separating the band from the rest of the sheet.

In an interview on 12/16/2021 at 12:55pm with Staff C, Staff J, and Staff k, they stated the fitted sheets created a ligature risk and could be used by a patient for the purpose of strangulation or hanging self.

Review of census sheet dated 12/7/2021 showed 31 patients. Review of the Psychiatric Evaluation and Admission Orders of these patients showed 7 of 31 patients to have been have had suicidal ideation and placed on suicide precautions at the time of their admission. Those patients were:

Patient #4.
57 y/o male admitted 12/3/2021 with suicidal ideation was placed into room 103A. Suicide precautions and self-harm precautions ordered by Staff X (NP) on 12/3/2021 at 10:22am.

Patient #13.
80 y/o male admitted 12/2/2021 with suicidal ideation was placed into room 109B. Suicide precautions ordered by Staff KK (MD) on 12/2/2021 at 6:35am.

Patient #14.
22 y/o male admitted 11/27/2021 with suicidal and homicidal ideation was placed into room 106A. Suicide precautions and self-harm precautions ordered by Staff KK (MD) on 11/27/2021 at 3:23pm. Census report for 12/7/2021 showed him to be in room 110A.

Patient #20.
78 y/o male admitted 11/18/2021 with major depression, severe; suicidal ideation with suicide attempt, and homicidal toward his wife was placed into room 107B. Suicide precautions and self-harm precautions ordered by Staff KK (MD) on 11/18/2021 at 6:51pm. Census report for 12/7/2021 showed him to be in room 201A.

Patient #22.
37 y/o female admitted 12/3/2021 with suicidal ideation was placed into room 203B. Suicide precautions and self-harm precautions ordered by Staff KK (MD) on 12/3/2021 at 9:33pm. Census report for 12/7/2021 showed him to be in room 203A.

Patient #23.
54 y/o male admitted 12/6/2021 with suicidal ideation was placed into room 204A. Suicide precautions and self-harm precautions ordered by Staff KK (MD) on 12/6/2021 at 3:30am. Census report for 12/7/2021 showed him to be in room 104A.

Patient #29.
74 y/o female admitted 11/26/2021 with suicidal ideation was placed into room 210A. Suicide precautions and self-harm precautions ordered by Staff KK (MD) on 11/26/2021 at 9:00pm.


E) Seclusion Rooms with Blind Spots.

Observation of the two seclusion rooms (rooms 034 and 035) on 12/8/2021 at 1:45pm showed each room to be about 10 feet by 10 feet. A door separated each seclusion room from the anteroom. The door had a window in it and was offset to the right of the center of the wall. Inside each room was a bed. Each bed was bolted to the floor in the center of the room. The bed was positioned horizonal to the door with one end of the bed butted against one of the side walls. The bed created a blind spot for the staff member standing outside the seclusion room door monitoring the patient. The surveyor stood in the corner of the seclusion room against the longest wall to one side of the door. Staff C (Corporate Clinical Officer) stated he could not see the surveyor in the corner of the room. Staff C also stated that the bed created a blind spot on the side of the bed furthest from the door. A video surveillance camera was in one corner of each seclusion room and in the anteroom. A panic button was outside of each seclusion room door.

Staff K (Corporate Security) joined the tour. In an interview with Staff K on 12/8/2021 at 2:15pm in the seclusion room, he stated that the camera fed a monitor in the nurse's station, adding, "A staff person is assigned to monitor the patient the entire time the patient is in seclusion. That's the policy." He also stated that there were no blind spots in the seclusion room when the cameras and video monitors were used. He concluded by saying that the cameras throughout the hospital can be, and are, monitored on a corporate level.

In interviews with Staff N (RN Supervisor) and Staff L (LVN) on 12/8/2021 at 2:20pm, both stated they had not been trained to assign someone to sit at the monitor to view patients in seclusion. Staff N stated that she "usually" has the monitor on, but no staff member is assigned to sit and view the monitor. Staff L stated that she did not know of a policy to have the monitor on, adding, she "may" turn it on and "occasionally" look at it. Both stated that a staff member is assigned to remain at the seclusion room door, monitor the patient the entire time the patient is in seclusion, and document observations on the rounds sheet.

In an interview with Staff B (DON) on 12/8/2021 at 2:20pm, she stated that the seclusion room is monitored by a staff member at the door outside of the seclusion room. She also stated that having the patient monitored by staff in the nurse's station is not a policy that is taught in orientation.

Record review of the "Restraint and Seclusion Log 2021" showed 4 patients (Patients 51, 52, 53, and 54) had been placed in seclusion. The dates ranged from 4/13/2021 through 9/18/2021.

Record review of policy 10577449, "Restraint or Seclusion Use," revised and approved 11/2021 showed: "Ongoing Assessment, Monitoring, and Evaluation During Restraint/Seclusion: Patients in simultaneous restraint and seclusion will be directly observed by one-to-one observation." The policy did not state that a staff member would be assigned to monitor a patient on a video screen in the nurse's station.


F) Bedroom 212 had unsecured contraband that was accessible to patients.

During observation on 12/7/2021 at 11:50am with Staff A (CEO), Staff C (CCO), Staff J (maintenance), and Staff K (security), it was noted the negative pressure room (bedroom 212) with adjoining anteroom was being used as a patient bedroom.

Record review of the patient census dated 12/7/2021 showed Patient #31 was assigned to room 212.

Further observation of the anteroom showed the cabinets and drawers were unlocked and filled with numerous contraband items (rubber gloves and other personal protective equipment; plastic trash liners; and numerous isolation supplies, such as gowns), giving patients access to these potentially dangerous items. The cabinet doors and drawers created ligature anchor points.

Staff A (CEO) and J (maintenance) stated the cabinets and drawers should be locked. Staff H (CNA) stated the cabinets and drawers needed to be locked for safety. She stated she did not have the key, adding that housekeeping might have it. Staff A stated the key had a designated place in the nurse's station, but the key was not there, and he was unable to locate it.

Record review of policy 9929981, "Ligature and Ligature Anchor Points - Risk Assessment," revised 1/2021, showed:
"DEFINITIONS:
Ligature - anything that could be used to bind or tie and potentially used for hanging/self-strangulation ...
Ligature Anchor Point - any piece of equipment, furniture, fixture, etc., that could be used to attach a string, rope, cord, or other material with the intent of hanging or strangulation ...
POLCIY ... The Safety/Environment of Care Committee shall be responsible for identifying and mitigating possible ligatures ... plastic bags ... closets, doors, door hinges ...
When identified ligatures or ligature anchor points cannot be immediately removed, Department Managers, in collaboration with the Safety/Environment of Care Committee, shall initiate mitigation strategies until the identified ligature and/or ligature anchor point risk can be eliminated or reduced."

Record review of policy 8797010, "Contraband," revised and approved 1/2020, showed:
"PURPOSE: To enhance safety by identifying and preventing dangerous items (contraband) from entering into the therapeutic environment ...
'Contraband' is a term used to describe prohibited or unauthorized items ... torn sheet ... hanging risks ... clothing associated with danger risk ... "


G) Environmental Risk Assessment missing ligatures and ligature anchor points.

Record review of policy 9929981, "Ligature and Ligature Anchor Points - Risk Assessment," revised 1/2021, showed:
"POLCIY: The facility's Safety/Environment of Care Committee shall be responsible for conducting environmental risk assessments and identifying the facility's possible ligatures and ligature anchor points. The Safety/Environment of Care Committee shall conduct environmental risk assessments annually.
The Safety/Environment of Care Committee shall be responsible for identifying and mitigating possible ligatures including ..."

On 12/7/2021, Staff A (CEO) provided a copy of the "Environmental Risk Assessment." Review of the assessment showed it was not dated. It did not include the gap between the desk and the wall that created a ligature anchor point in 24 of 24 bedrooms on the 100 and 200 units. The assessment did not include the loose metal paper towel dispensers that created a ligature anchor point in 5 of 24 bathrooms on the 100 and 200 units. It did not include the fitted sheets or the blind spots in the seclusion rooms.

On 12/8/2021Staff A (CEO) stated that the findings in this survey, which included bedroom and bathroom ligature anchor points, fitted sheets, blind spots in the seclusion rooms, and unlocked cabinets and drawers of room 212, had not been identified and documented on the "Environmental Risk Assessment" by members of the Safety/Environment of Care Committee.


H) Housekeeping cart safety.

Observation of Staff F (Housekeeper) on 12/7/2021 at 11:45am showed her in room 104 on the 100-unit cleaning with her back to the door. Her housekeeping cart was outside the bedroom door. The cart was unlocked. Behind unlocked doors on the cart was 73 Disinfecting Acid Bathroom Cleaner, Bio-Enzymatic Odor Eliminator, a box of extra-large vinyl gloves, and large black plastic trash bags. Attached to one end of the cart was a broom with an approximate four-foot handle. On the other end was two mops with approximate four-foot handles.

In an interview with Staff F (Housekeeper) on 12/7/2021 at 11:45am, she stated, "This is my second day." She stated she had not had training to keep the cart locked, adding she did not know the cart should be positioned for safety when cleaning patient bedrooms.

In an interview with Staff G (Housekeeper) on 12/7/2021 at 11:46am, she stated she was training Staff F. She also stated the cart was supposed to be locked and should be in view of the housekeeper when cleaning patient bedrooms.

Observation of Staff I (Housekeeper) on 12/7/2021 at 12:10pm showed her in room 207 on the 200 unit cleaning the room with her back to the door. Her housekeeping cart was outside the bedroom door. Attached to one end of the cart was a broom with an approximate four-foot handle. On the other end was two mops with approximate four-foot handles.

In an interview with Staff I (Housekeeper) on 12/7/2021 at 12:10pm, she stated she had not thought about the brooms and mops being used as weapons by patients.

In an interview with Staff C (CCO) and Staff J (maintenance) on 12/16/2021 at 4:55pm, they stated the housekeeper's orientation did not include a written policy and procedure on monitoring the housekeeping cart, adding there was no such policy. They also stated there was no competency or check-off list that documented written and/or verbal training on monitoring the housekeeping carts. Staff C stated the housekeeping cart needed to be locked and the mops and brooms could be used as weapons and needed to be secured.




43549


Failure to monitor patient on a 1:1

Based on observation, record review and interviews the facility failed to monitor patients at the level of monitoring most recently specified in the patient's medical record for 1 of 2 patients (Patient 10) with orders for 1:1 monitoring. Specifically, the facility failed to ensure that Certified Nursing Assistant, employee #Z kept patient #10 that she had been entrusted to provide continuous 1:1 monitoring on in her sightline. This resulted in unmonitored and unobserved activity by employee #Z for thirty-five minutes, 1340 to 1415.

The findings include:

Patient #10 was admitted 12/05/21 as an Emergency Detention due to a psychotic at a mall. Admission diagnoses were Bipolar Disorder, type I, mixed episode with manic episode, rule out Obsessive Compulsive disorder. The psychiatrist documented behaviors of mania with bizarre behaviors, agitation, aggression, threatening others, paranoia and psychotic symptoms. Orders dated 12/05/21 included assault and elopement precautions and unit restriction.
Patient #10 had at least daily violent outbursts/attacks toward others and received emergency medications daily 12/06 and 12/08 through 12/12/21. The patient was also routinely refusing scheduled medications. On 12/12/21 the psychiatrist ordered 1:1 sitter for aggressive behavior. This monitoring order remained in place 12/15/21.

POLICY: " Patient Observation" Revised 05/21 read:

PROCEDURE:
1. On admission, the patients will be assessed for the level of observation. The Provider will order the one of two observation levels. All patients will be admitted to the patient care unit with a minimum of "every 15 minutes" observation level.
2. Observation levels can be increased or decreased by a provider's order.

A. Provider's orders: Providers will order specific observations for any patient(s) who require level of monitoring other than routine, including but not limited to:
1. Assault
2. Aspiration
3. Elopement
4. Fall
5. Self-Harm
6. Seizure
7. Sexually acting out
8. Suicide

B. Observation Levels: A frequency or intensity of observation assigned to a patient during which a health care professional, or their designee, will observe a patient. The approved observation levels are:

1. Level I- General Observation, Every 15 minutes
2. Level II - 1:1 Observation
a. The patient is to be under constant visual observation by an assigned staff member, regardless of other unit activities.
b. Staff member must remain in close proximity to the patient, to include patient bathing and toileting activities. Under these conditions, the patient safety and protection outweigh his / her right to privacy. For bathing in toileting activities, staff the same sex may be utilized.
c. Staff will continuously monitor the patient's behavior and immediately report any changes in conditions of circumstances to nurse.
d. Staff is not to engage in personal activities such as reading, eating, for use, or similar activity that could distract or otherwise interfere with the continuous observation of the patient.

Observation of the Unit 100 male's dayroom on initial tour, 12/15/21 at 1340 with employee (#2), the Director of Nursing, reviled six adult males in the day room with two nursing assistants (NA) (#DD & II) talking to patients and certified nursing assistant (CNA) #Z standing alone leaned against a table watching television and glancing around the dayroom at times.

During an interview 12/15/21 at 1342 NA # DD stated two patients (# 10 & #14) were assigned 1:1 monitoring. She pointed out NA # II walking with patient #14. When interviewed 12/15/21 at 1344 NA # II stated she was monitoring patient # 14 as a 1:1 so he was never out of her sight or area. She stated the other 1:1 was patient #10 and said he was not in the dayroom. She then pointed to his room.
CNA #Z remained in the dayroom against the table watching television and glancing around the dayroom at times.

This surveyor knocked on patient #10's door and peeked inside. Patient #10 was lying in bed with his back to the door and did not stir. This surveyor approached employee A, the Director of Nursing and asked where patient 10 and his 1:1 staff were. She checked with the unit nurse and informed me that he was with his CNA. At 1415 this surveyor knocked again on patient 10's door and heard a female voice say "yes." Upon entering patient 10 remained in bed as before. CNA #Z was sitting in the room facing the patient's back.

When Interviewed 12/15/21 at 1415 CNA #Z stated she had not been in patient #10's proximity "because he said he didn't like it." She added "He's okay with it now."

Interview on 12/15/2021 at 1430 with employee #B Director of Nursing she stated saw the CNA in the dayroom and not with patient #10. She stated the CNA "knows better than that."

Based on observation, interview, and record review, the facility failed to ensure that 28 of 28 patient (Patient #'s 2, 3, 4, 5, 6, 8, 9, 10, 11, 13, 14, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, and #33), staff, visitors, and contractors were provided a sanitary environment to avoid sources and transmission of infections and communicable dise

Based on record review and interview:

A) The facility failed to ensure that 31 of 31 patients (Patients 1-31) were protected from potential abuse, neglect, and harassment as evidenced by 1 of 9 new hires (Staff F) was hired without a pre-employment criminal and national sex offender background check;

B) The facility failed to ensure that future patients within the community were safe from abuse, harassment, and sexual misconduct by 2 of 2 staff member (Staff OO and Staff PP); and

C) The facility failed to ensure that administrative staff had initiated an investigation into the fall of 1 of 1 patient (Patient #32) in which the patient sustained several fractures.

Findings included:

A) No Background Check.

Record review of the personnel file of Staff F showed that the background check and urine drug screen had not been completed.

Observation of room 104 on the 100 unit on 12/7/2021 at 11:45am showed Staff F cleaning the room. In an interview with Staff F, she stated she had started working the previous day, 12/6/2021.

Review of the personnel file for Staff F (housekeeper) showed she had been hired on 12/6/2021. Further review of her file showed that there was no background check.

In an interview with Staff NN (HR Director) on 12/9/2021 at 3:15pm, she stated that the background check is sometimes in progress when an individual is hired. When clarification was sought, she stated that an individual can be hired without a background check.

In an interview with Staff C (CCO) on 12/9/2021 at 3:50pm, he stated that there was a CMS waiver in place for obtaining background checks prior to beginning work. A copy of the waiver was requested. A copy of the "COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers" was received, along with policy 10862386, "Employee Health Services - Human Resources."

Review of the "COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers," updated 5/24/2021, showed the following waiver for Provider Enrollment: "Waive the following screening requirements: ... Criminal background checks associated with fingerprint-based criminal background checks ... 42 CFR§424.518."

Review of policy 10862386, "Employee Health Services - Human Resources" showed,
"PURPOSE: To provide a consistent process for employees to be assessed medically and deemed capable of performing the essential functions of their position.
POLICY: A candidate is hired conditioned upon successful completion of the medical assessment which includes drug screening and TB screening ...
9. COVID DELAYS: Due to possible delays from medical screening providers as a result of closures or short-staffing due to the current COVID-19 pandemic, new hires will be offered employment contingent upon successful results of all medical screenings, which may be received after the employee's start date."

In another interview with Staff C (CCO) on 12/9/2021 at 4:00pm, he stated the waiver he found did not apply to the criminal background check.


B) Allegations of Patient Abuse and Sexual Misconduct.

Record review of Intake TX00402462 dated 12/13/2021 at 11:12am, it was reported that on 11/14/2021 Staff OO (CNA) and Staff PP (CNA) "mocked" Patient #47 about the size of his penis. They told him that his penis was smaller than that of another patient. Staff OO told Patient #47 that her cousins would beat him up. Staff PP told Patient #47, "I've got to make sure my bond money is straight because I am about to go to jail today because you've got me fucked up." Patient #47 reported to Staff OO that his roommate had urinated on the floor in his bedroom. Staff OO replied, "Go to the room and drink the piss off the floor."

Record review of Psychiatric Hospital Incident Report by Staff A (CEO) dated12/16/2021 [not timed] showed:
"SUMMARY: On 11/30/2021, it was reported to management that two CNAs were involved in a verbal altercation with a patient [Patient #47] ... he was upset and agitated after a phone call with his family ... two CNAs [Staff OO and Staff PP] ... began to yell at the patient to return to his room. The patient then threatened to slap the two CNAs. Staff OO and Staff PP yelled at the patient. It was reported that the two CNAs told the patient to 'find your mother to whine, shine, whine, whine' and 'go suck your mother's nipples you little ass boy.' It was also reported that the two CNAs told the patient that another patient in the unit has 'a larger dick than yours' and asked the other patient to come pull his privates out. In addition, Staff OO told the patient, 'You are only doing this for attention because you are not getting the love you need at home' and 'I will call my cousin to beat your ass.' At this time the patient returned to his room to calm down when he found urine on the floor left by another patient. The patient ... came out of his room to alert staff and it was reported that Staff OO told the patient to 'go drink your pee.'

"INVESTIGATION: The initial reporter was interviewed and asked to write her statement of the events that transpired that day. On 11/30/2021, the day of the report, both Staff PP and Staff OO were suspended pending the results of the investigation. CEO and DON interviewed other witnesses, gathered statements, and reviewed the video footage. Witness statements and the video footage corroborated the initial report. Staff PP and Staff OO were contacted and asked to provide their statements. Staff PP and Staff OO were terminated.

"ACTIONS: Termination of alleged perpetrator."

Record review of Personnel Action Form by Staff A (CEO) and Staff NN (HR Director) dated 11/30/2021 [not timed] showed Staff OO was terminated and ineligible for rehire.

Record review of Personnel Action Form by Staff A (CEO) and Staff NN (HR Director) dated 11/30/2021 [not timed] showed Staff PP was terminated and ineligible for rehire.

In an interview with Staff C (CCO) on 12/15/2021 at 4:03pm, he stated that the allegations of abuse by Staff OO and Staff PP had not been reported to the CNA registry. He also stated he had not known that the comments made Staff OO and Staff PP had been personal attacks toward Patient #47.

In an interview with Staff B (DON) on 12/16/2021 at 11:00am, she stated she found out about the conduct of Staff OO and Staff PP on 11/30/2021, adding that the incident occurred on 11/14/2021, just over two weeks earlier.


C) Proper investigation following Patient #32's fall.

Record review of the Psychiatric Evaluation by Staff KK (MD) dated 10/14/2021 at 12:15pm showed Patient #32 readmitted for increasing agitation and aggressive behavior. He had been wandering into female patient's rooms at the nursing home and hit two staff members. He had recurrent falls.
Diagnostic impression: Major neurocognitive disorder, unspecified, with behavioral disturbances; unspecified anxiety disorder; and unspecified depressive disorder.

Record review of the History & Physical by Staff X (NP) dated 10/13/2021 at 12:36pm showed the patient to be a "high fall risk" with a history of repeated falls and muscle wasting.

In an interview with Staff WW (CNA) on 12/16/2021 at 10:25am, she stated that on 11/18/2021, she was providing one-on-one observation. She "heard a noise" that sounded "like someone hit the floor hard." This occurred "before breakfast, around 7:45am." She "peeked" into Patient #32's room and saw that he was on the floor. She summoned help. Patient #32 was put back into the bed by staff and "he didn't get back up." He was gotten up for lunch and "fell again and put in a wheelchair. His arm looked broken." She stated she did not hear anyone go into Patient #32's room just prior to the fall.

Record review of Daily Nursing Narrative by Staff B (CNO) dated 11/18/2021 at 12:00pm showed patient was on the "floor lying between beds. Complained of pain left elbow. X-ray here. Fracture to left elbow. Orders received to transfer per ambulance to [medical facility]. Family notified of fall and transfer to hospital."

Record review of Physician Orders by Staff X (NP) dated 11/18/2021 at 1:10pm showed an order for a STAT [immediate] x-ray of the left elbow. At 1:45 Staff X (NP) ordered a transfer out by ambulance for treatment of a left elbow fracture.

Record review of incident report by Staff P (RN) dated 11/18/2021 (no time) showed an order to send the patient out for medical treatment at 1:45pm. He was transferred at 2:28pm.

Record review of the medical record for Patient #32 showed that the Patient Safety Observation Round for 11/18/2021 was missing.

In an interview with Staff XX (Medical Records) on 12/16/2021 at 11:30am, she stated she could not find the Patient Safety Observation Round for 11/18/2021. In addition, Staff B (DON) and Staff C (CCO) stated they did not know the location of the missing round sheet.

In an interview with Staff C (CCO) on 12/10/2021 at 12:55pm, he stated that there needed to be a root cause analysis conducted on Patient #32's fall in which he sustained fractures, adding he would conduct that investigation on 12/13/2021.

Based on observation, record review, and interview, the facility failed to ensure that the identify of 31 of 31 patients (Patients 1-31) remained confidential as evidenced by 31 of 31 patients had their full names on the spine of their medical records. In addition, 18 of 18 patients (Patients 1-18) had their full names on a white board mounted in the nurse's station.

Findings included:

Record review of policy 9857907, "Patient Rights and Responsibilities Texas," revised and approved 5/2021, showed:
"PURPOSE: Every person who enters the hospital for care has rights ... You have the right to ... personal privacy and confidentiality of information."

Record review of "Rights and Responsibilities" in the Patient Handbook (no date) showed, "You have the right ... [to] have your privacy, confidentiality, and security needs respected by the organization."

During a tour of nurse's stations on units 100 and 200 on 12/7/2021 at 11:30am, it was observed that the top two-thirds of three sides of the nurse's stations was glass. The full name of each patient was documented on the spine of the patient's medical record. The medical records were stored in a chart rack when not in use. Staff members had moved several of the charts to the documentation stations just inside of and below the glass. On one of the walls in the nurse's station was a white board that documented the full names of the patients. The names of the patients on the spines of the medical records and on the white board were visible when viewed from outside the nurse's station.

In an interview with Staff B (DON) on 12/7/2021 at 11:30am, she stated, "We've thought about that," adding that the full name of patients should not be visible to other patients or visitors standing outside of the nurse's station.

Based on review of records and interview, the facility failed to provide evidence of an ongoing QAPI program that showed measurable improvement in indicators for 3 of 4 quarters of 2021.

Findings included:

Record review of the Medical Staff Bylaws amended 9/2020 showed:
"9.3 MEDICAL STAFF COMMITTEES ... (b) QUALITY COMMITTEE ... The quality committee will meet at least quarterly ... The Medical Staff Committees shall meet as needed, but at least quarterly and maintain a permanent record of its proceedings and actions."

Record review of the "Quality Assurance & Performance Improvement Workplan (QAPI 2021" showed: "The ... Quality Review Committee meets quarterly ... Data will be collected monthly for all quality indicators and will be submitted to the ... Quality Council. A report, which will provide summary data about the indicators, will be prepared for the Medical Executive Committee and Governing Board."

Record review of the Quality Council Meeting minutes showed one meeting on 12/1/2021.

Record review of the Medical Staff Meeting minutes showed evidence of two Quality Council Meetings for 2021. Those Medical Staff Meeting minutes showed approval of Quality/PI minutes on 8/3/2021 and 11/11/2021.

Record review of the Governing Board Meeting minutes dated 5/6/2021 showed evidence that Quality/PI minutes were approved.

In an interview with Staff C (CCO) on 12/16/2021 at 5:00pm, he stated he only had one set of QAPI minutes and none of the supporting evidence, adding the individual responsible for QAPI left and he was unable to find all of the minutes and supporting data.

Record review of the minutes for Quality Council Meeting, Medical Staff Meeting, and Governing Board Meeting (as noted above) that there was four QAPI presentations in 2021: 5/6/2021, 8/3/2021, 11/11/2021, and 12/1/2021.

Based on observation, record review, and interview, the facility failed to ensure that 3 of 3 RNs (Staff HH, Q, and Staff CC) assigned the nursing care of each patient to other nursing personnel. Specifically:
A) The facility failed to ensure that Staff HH (RN) assigned a one-on-one to a CNA;
B) The facility failed ailed to ensure that Staff Q (RN) assigned the nursing care of 13 of 13 patients (Patients 19-31) to an RN; and
C) The facility failed ailed to ensure that Staff CC (RN) had completed the assignment sheet in a timely manner.

Findings included:

Record review of policy 8821183, "Nursing Acuity Plan," revised and approved 9/2020, showed:
"A staff member will be assigned exclusively to an individual if the patient requires continuous 1:1 monitoring. Another aide/tech or nurse ... will be assigned to make rounds, supervision, and safety checks for other patients. Staffing decisions are a collaborative effort among all staff, along with the Director of Nurses. When additional resources are warranted, unit assignments can be changed."

Observation of room 110 on 12/7/2021 at 11:30am showed Patient #14 in the bed. Staff M (CNA) was in the room with the patient.

In an interview with Staff B (DON) on 12/8/2021 at 12:50pm, she stated that Staff M (CNA) was providing a one-on-one observation for Patient 14, a potentially dangerous male patient. She stated the charge nurse completes the assignment sheet and picks specific staff member to conduct the 15-minute rounds. She also stated that these assignments are documented on the "Shift Assignment" sheet.

Record review of the "Shift Assignment & Patient Acuity" dated 12/7/2021 for unit 100 showed that Staff HH (RN) had made the following assignments:
Rooms 101-103 were assigned to Staff GG.
Rooms 104-106 were assigned to Staff II.
Rooms 107-109 were assigned to Staff JJ.
Rooms 110-112 were assigned to Staff M.
Though Staff M had been seen in room 101 providing the one-on-one for Patient 14, she was also assigned rooms 110-112. The Assignment Sheet did not specify a staff member to be responsible for the one-on-one on Patient 14.

Record review of the "Shift Assignment & Patient Acuity" dated 12/7/2021 for unit 200 showed that Staff Q (RN) had made the assignments. She did not assign an RN for the patients.

In an interview with Staff CC (RN) on 12/10/2021 at 9:45am, he stated that he had not completed the "Shift Assignment & Patient Acuity" for unit 100. In an interview with Staff B (DON) on 12/10/2021 at 9:46am, she stated the assignment sheet should have already been completed at the beginning of the shift by Staff CC (RN).

Based on observation, interview, and record review, the facility failed to ensure that 3 of 3 patients (Patients 12, 26, and 31) were being administered medications that were not potentially cross contaminated with other medications. In addition, the facility failed to ensure that 2 of 2 nursing staff (Staff L and Staff Q) were properly trained on and adhered to the policies and procedures on the proper use of pill cutters.

Findings included:

Record review of policy 9452720, "Splitting and/or Crushing Medications," revised and approved 4/2021 showed: "PURPOSE: To ensure medications are prepared by authored individuals in a safe manner to meet the needs of the patient ... Each patient is assigned an individual pill splitter if they have a medication needing to be split ... The pill splitter is placed in a plastic bag and a patient label is placed on the exterior of the bag ... The pill splitter is stored in the patient specific bin for internal medications ... When a pill must be split, the assigned pill splitter for the patient is utilized ... To prevent cross-contamination, clean after each use ..."

Observation on unit 100 on 12/8/2021 at 12:00pm showed Staff L (LVN) at the automated medication dispensing station. On the counter was a pill cutter that had residual pill powder in it.

In an interview with Staff L (LVN) during the observation, she stated that the substance in the pill cutter was from a medication that had been split previously. She also stated that the pill cutter was used on multiple patients, but she cleaned it between patients. Staff B (DON) identified the patient as Patient #12.

In an interview with Staff N (RN Supervisor) on 12/8/2021 at 12:05pm, she stated the pill cutter is to be cleaned between patients.

In an interview with Staff B (DON) on 12/8/2021 at 12:15pm, she stated a pill cutter cannot be used on multiple patients because of medication cross contamination.

Observation on unit 200 on 12/8/2021 at 12:10pm showed Staff Q (Agency RN) at the nurse's station. In an interview with her, she stated that there should be one pill cutter for each patient. She opened a cabinet drawer and showed that there were two pill cutters in the drawer for two patients that needed to have their pills split. It was noted that the pill cutters had residual pill powder in them. Neither of the pill cutters were labeled with a patient's name. Staff B (DON) identified the patients as Patient 26 and 31. Staff Q could not identify which pill cutter belonged to either patient. Staff Q (Agency RN) stated the pill cutters should be labeled and that she could not assure which pill cutter belonged to Patient #26 or Patient #31.

In an interview with Staff S (Executive Assistant) on 12/8/2021 at 12:00pm in the nurse's station on unit 100, she stated that a pill cutter cannot be used on multiple patients, adding that each patient needed their personal pill cutter. She concluded by saying that the pill cutter can be sent home with the patient.

Based on record review and interview:
A) The facility failed to ensure safe administration of a psychotropic medication to 1 of 1 patient (Patient #14) by Staff P;
B) The facility failed to provide adequate training and competency assessment on the administration of psychotropic medications as part of new-hire orientation to 6 of 6 licensed staff (Staff L, N, P, Q, LL, and Staff MM); and
C) The facility failed to ensure adequate training was completed by 1 of 1 staff members (Staff P) prior to returning to work following the administration of the wrong psychotropic medication to Patient #14.

Findings included:

Record review of Provider Orders for Patient #14 showed that Staff KK provided a telephone order for Haldol 10mg intramuscular once now for agitation on 11/28/2021 at 3:31pm. The order was received and documented as an "emergency medication" by Staff P (RN). Patient #14 had "pushed another patient to the floor, hostile / aggressive toward other patients." Alternative actions to the emergency medication that had been attempted included diversion activity, redirection of behavior, verbal 1:1 intervention, reduction of stimuli and companionship.

Record review of "Haloperidol (Route of Administration for People with Schizophrenia" by Hanafi, et al., published online 10/19/2017 (reviewed on U.S. National Library of Medicine - National Institutes of Health) showed: " ... Haloperidol lactate is a short acting parenteral solution for intramuscular and intravenous administration. Haloperidol decanoate is a long?acting intramuscular preparation ...
Haloperidol is one of the most commonly used interventions to treat schizophrenia ... Intramuscular haloperidol lactate is used for prompt control of patients with acute agitation ... Another parenteral form, haloperidol decanoate provides slow and prolonged release when administered as a depot intramuscular injection ... which helps eliminate the problems of non?compliance."

In an interview with Staff T (pharmacist) on 12/8/2021 at 4:05pm, he stated he found that Haldol Decanoate had been removed from the medication dispensing system instead of the prescribed Haldol Lactate on 11/28/2021 by Staff P (RN) the following day, 11/29/2021. He immediately notified Staff B (DON) of the incident.

In an interview with Staff B (DON) on 12/8/2021 at 2:40pm, she stated she could not locate her notes on the medication error made by Staff P (RN). She reconstructed her actions and presented that documentation. Review of that documentation dated 11/29/2021 showed that Staff P (RN) met with Staff B (DON) the day after the incident. Staff B (DON) asked Staff P (RN) if he "understood the difference between Haldol and Haldol Decanoate." He said, "No." Staff B (DON) instructed Staff P (RN) "to write up Haldol Dec and Haldol to learn the difference."

On 12/9/2021 at 3:50pm, Staff B (DON) presented an "Inservice Training Record" for Staff P (RN) she had conducted. Staff P (RN) verbalized an understanding of the difference between the two medications in question. Staff B (DON) also stated there was no behavioral health medication training with post-assessment or self-assessment of behavioral health medication competency provided during orientation.

In an interview with Staff B (DON) and Staff C (CCO) on 12/10/2021 at 10:05am, Staff B (DON) stated that it would be "beneficial to have education review for psychotropic meds." Staff C (CCO) stated that they have discussed medication training for "high-risk meds."

Record review of the personnel file of Staff P (RN) showed:
o Bachelor of Science in Nursing on 6/6/2015;
o Orientation 6/28/2021;
o Five previous employers - no behavioral health nursing experience; and
o Application - Reason for leaving most recent employer - "seeking experience in behavioral health."

In an interview with Staff P (RN) on 12/10/2021 at 9:49am, he stated he had been given training material from Staff B (DON) on the difference between Haldol Decanoate and Haldol Lactate. He also stated he worked one shift between the time he was given the training material and the time he read it. He went on to say that there had been no training on behavioral health medications in orientation, and that he and all newly hired licensed employees would benefit from his training.

Record review of the personnel files of Staff L (LVN), Staff N (RN Supervisor), Staff P (RN), Staff Q (RN), Staff LL (RN), and Staff MM (RN) showed that there was no behavioral health medication training with post-assessment or self-assessment of behavioral health medication competency provided during orientation.

Based on record review and interview the facility failed to ensure that the Patient Safety Observation Rounds were completed for 1 of 1 patient (Patient #32). This failure resulted in 5 of 5 Patient Safety Observation Round sheets with missing information and 6 of 6 Patient Safety Observation Rounds missing from the chart.

Findings included:

Review of the policy 9742509, "Patient Observation," revised and approved 5/2021, showed:
"POLICY:
... Patients will ... be assessed and monitored during their treatment to ensure observation levels are appropriate ... 6. Documentation: ... Documentation of all observations will be completed in the patient's record at least once per 15-minute increment ... Staff will complete the patient observation record using a coding system described on the Patient Observation Monitoring Form ... Staff will initial, date, and/or time appropriate documentation in the designated areas each 15-minute observation of a patient."

Record review of the Patient Safety Observation Rounds form showed that for each 15-minute increment the following information was to be documented: staff initials, location of the patient, and behaviors. The form included a coding system for the location of the patient and behaviors.

Review of the Patient Safety Observation Rounds for Patient #32 showed the following areas to be incomplete:
9/24/2021 at 3:45pm - 6:45pm: no staff initials
9/26/2021 at 11:15am - 12:45pm: behaviors not documented by Staff TT (tech)
9/27/2021 at 12:45pm: behaviors not documented by Staff AA (CNA)
9/30/2021 at 5:00am - 5:45am: no staff initials
10/17/2021 at 1:15pm - 1:30pm: no location or behavior documented by Staff PP (CNA)

Record review of the Patient Safety Observation Rounds for Patient #32 showed the following days missing from the chart: 10/24/21, 10/29/21, 11/14/21, 11/18/21, 11/20/21, and 11/22/21.

In an interview with Staff XX (Medical Records) on 12/16/2021 at 11:30am, she stated she could not find the missing Patient Safety Observation Round sheets.

Based on observation, record review, and interview, the facility failed to ensure that the Interdisciplinary Treatment Plan for 1 of 1 patient (Patient #32) contained short-term and long-term goals that were relevant and obtainable.

Findings included:

Record review of policy 8816970, "Patient Treatment Plan," revised and approved 1/2020, showed:
"POLICY:
Each patient shall have a written, comprehensive, individualized treatment plan that is based on assessment of his/her medical, clinical, and nursing needs. Individualized treatment planning shall be based on patient need ...
6. Long-term goals [and] ... short-term goals that are: ... Individualized to the patient's needs ... Appropriate for the identified problems ... Described as specific behavioral outcomes for the patient (observable, measurable)."

Record review of the Psychiatric Evaluation by Staff KK (MD) dated 9/21/2021 at 11:12pm showed a 67-y/o male admitted with a history of dementia with behavioral disturbances. He had hit another resident with his casted arm. He had been verbally aggressive and threatening to staff, making racial slurs. He had a history of recurrent falls, muscle wasting and atrophy, recent fracture of lower right [actually, left] radius bone, and major neurocognitive disorder. Mental Status Examination showed mumbling speech, disorganized thought processes; attention span and concentration decreased; immediate, recent, and remote memory grossly impaired; and insight and judgment impaired.
Diagnostic impression: Major neurocognitive disorder with behavioral disturbances, insomnia, and rule out depression.

Review of the History & Physical by Staff RR dated 9/21/2021 at 12:00pm showed the patient "walking around very confused ... unable to answer questions."
Impression and Plan: Recurrent falls. Fall Precautions. Cast left upper extremity.

Record review of the Interdisciplinary Treatment Plan for Patient #32 dated 9/20/2021 [no time and no author] showed the following goals that were unobtainable for this patient with a "major neurocognitive disorder," "mumbling speech," and "disorganized thought processes":
Problem: Falls
Short-Term Goal - Patient will notify staff when needing assistance. Target Date: 9/27/2021
Short-Term Goal - Patient will utilize call button when in room. Target Date: 9/27/2021
Long-Term Goal - Patient will verbalize understanding of risk factors that contribute to possibility of falls and will identify ways to correct situation if able. Target Date: 10/4/2021

Review of Admission Orders by Staff RR (NP) dated 9/21/2021 at 8:20pm and subsequent Physician's Orders showed no order for Fall Precautions.

Further record review of the Interdisciplinary Treatment Plan for Patient #32 dated 9/20/2021 [no time and no author] showed:
Problem: Adequate Nutrition
Short-Term Goal - Patient will report improved appetite and is observed by staff to eat at least [blank] % of meal daily by [blank] days of admission. Target Date: 9/27/2021
Short-Term Goal - Patient will consume proper fluid intake to maintain bodily functions. Target = [blank] ml of fluids daily by [blank] days of admission

Review of Admission Orders by Staff RR (NP) dated 9/21/2021 at 8:20pm showed an admission weight of 158.6 lbs., regular diet with double protein. Further review of the Admission Orders and subsequent Physician's Orders did not reveal an order to monitor the weight or a dietary consult.

In an interview with Staff C (CCO) on 12/9/2021 at 1:00pm, he stated that there were problems with the treatment plans.

In an interview with Staff UU (MSW) on 12/16/2021 at 3:45pm, she stated that there were problems with the development of treatment plans and modalities.

Based on record review and interview, the facility failed to ensure that the Interdisciplinary Treatment Plan for 1 of 1 patient (Patient #32) identified active treatment measures or interventions to be utilized by staff.

Findings included:

Record review of policy 8816970, "Patient Treatment Plan," revised and approved 1/2020, showed:
"POLICY:
Each patient shall have a written, comprehensive, individualized treatment plan that is based on assessment of his/her medical, clinical, and nursing needs. Individualized treatment planning shall be based on patient need ...
8. Treatment modalities/interventions for each goal that are: ... Individualized to the patient's needs ... Focused on the identified problems ... A realistic and appropriate means for achieving the identified goals ... Stated as specific interventions rather than general services."

Record review of the Psychiatric Evaluation by Staff KK (MD) dated 9/21/202111:12pm showed a 67-y/o male admitted with a history of dementia with behavioral disturbances. He had hit another resident with his casted arm. He had been verbally aggressive and threatening to staff, making racial slurs. He had a history of recurrent falls, muscle wasting and atrophy, recent fracture of lower right [actually, left] radius bone, and major neurocognitive disorder. Mental Status Examination showed mumbling speech, disorganized thought processes; attention span and concentration decreased; immediate, recent, and remote memory grossly impaired; and insight and judgment impaired.
Diagnostic impression: Major neurocognitive disorder with behavioral disturbances, insomnia, and rule out depression.

Review of the History & Physical by Staff RR dated 9/21/2021 at 12:00pm showed the patient "walking around very confused ... unable to answer questions."
Impression and Plan: Recurrent falls. Fall Precautions. Cast left upper extremity.

Record review of the Interdisciplinary Treatment Plan for Patient #32 dated 9/20/2021 [no time and no author] showed:
Problem: Falls
There were no interventions provided.

Further record review of the Interdisciplinary Treatment Plan for Patient #32 dated 9/20/2021 [no time and no author] showed:
Problem: Adequate Nutrition
There were no interventions provided.

Additional record review of the Interdisciplinary Treatment Plan for Patient #32 dated 9/20/2021 no time and no author] showed no interventions for the problems of Chronic/Acute Pain and Intrusive Behavior.

In an interview with Staff C (CCO) on 12/9/2021 at 1:00pm, he stated that there were problems with the treatment plans.

In an interview with Staff UU (MSW) on 12/16/2021 at 3:45pm, she stated that there were problems with the development of treatment plans and modalities.

Based on record review and interview, the facility failed to ensure that a Psychiatric Evaluation was completed and available to the treatment team for 5 of 14 patients (Patients 11, 13, 32, 35, and 36) within 60 hours (2 ½ days) of admission. The Psychiatric Evaluation was not available to the treatment team on an average of 10 days, potentially compromising patient safety and quality of care.

Findings included:

Record review of policy 8808841, "Psychiatric Evaluation," revised and approved 1/2020, showed:
"POLICY: Each patient receives a psychiatric evaluation that must ...Be completed within 60 hours of admission."

Record review of the "Rules and Regulations of the Medical Staff" adopted 9/2020 showed: "PSYCHIATRIC EVALUATION
Each patient must receive a psychiatric evaluation. The psychiatric evaluation is done for the purpose of determining the patient's diagnosis and planned treatment ... The psychiatric Evaluation must be completed within 60 hours of admission."

In an interview with Staff C (CCO) on 12/9/2021 at 1:00pm, he stated the Psychiatric Evaluation should be completed within 60 hours of admission. He also stated that a delay in dictating the Psychiatric Evaluations had been identified as a problem.

5 of 10 Psychiatric Evaluations (Patients 11, 13, 32, 35, and 36) were found to be late as a result of the delay in dictation by a physician. Those Psychiatric Evaluations are listed follow:

Patient #11.
Record review of "Psychiatric Evaluation" by Staff KK showed: 64 y/o male with a past medical history of diabetes mellitus, seizure disorder, benign prostate hyperplasia, anemia, schizoaffective disorder, returning from the acute care hospital for continued treatment of agitation, aggressive behavior, and acute decompensation of his schizoaffective disorder.
Admission date 11/9/2021, dictation date 11/14/2021 at 12:27pm, and electronically signed and verified 11/15/2021 at 9:38am. Available to treatment team on day 5.

Patient #13.
Record review of "Psychiatric Evaluation" by Staff KK showed: 80 y/o male with a history of major depression, major neurocognitive disorder, behavioral disturbance, and threats to kill himself. Medical history was significant for hypertension, recent COVID-19 infection, hypothyroidism, and dementia. He had been sexually inappropriate with staff.
Admission date 12/1/2021, dictation date 12/5/2021 at 6:30pm, and electronically signed and verified 12/7/2021 at 2:23pm. Available to treatment team on day 4.

Patient #32.
Record review of "Psychiatric Evaluation" by Staff KK showed: 67 y/o male with a history of dementia, coronary artery disease, GERD, muscle wasting, spinal stenosis, osteoarthritis, chronic back pain, and hyperlipidemia. He had been agitated, aggressive, confused and disoriented. Speech was minimal. He had a closed fracture of olecranon process left ulna from a recent fall.
Admission date 11/20/2021, dictation date 11/28/2021 at 4:24pm, and electronically signed and verified 11/29/2021 at 8:30am. Available to treatment team on day 8.

Patient #35.
Record review of "Psychiatric Evaluation" by Staff KK showed: 32 y/o male with a history of seizure disorder, intellectual disability disorder, and autism spectrum disorder. He presented with agitation, aggression, destruction of property, extreme lability, and refusal of medications.
Admission date 11/22/2021, dictation date 12/3/2021 at 2:30am, and electronically signed and verified 12/3/2021 at 10:36am. Available to treatment team on day 11.

Patient #36.
Record review of "Psychiatric Evaluation" by Staff KK showed: 44 y/o male with a history of increasing agitation, anger, verbally aggressive behavior, and suicidal ideation. He presented with a history of spinal injury with resultant paralysis waist down. He was wheelchair bound.
Admission date 10/23/2021, dictation date 11/14/2021 at 3:42pm, and electronically signed and verified 11/15/2021 at 10:24am. Available to treatment team on day 22.