HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to adequately supervise and provide a safe environment for one of eight sampled patients (Patient 1) who had aggressive behaviors. This failure resulted in Patient 1 barricading himself in the dayroom causing harm to himself, staff, and destruction of hospital property.

Findings:

During a concurrent observation and interview on 8/14/24 at 9:29 a.m. with Director of Plant Operations (DPO) in Unit 200 dayroom, there were large pieces of paper covering all the windows and door of the dayroom. There were eight chairs in the patient hallway. DOP stated, "Dayroom is requiring some maintenance and cannot be used by patients. Patio is also closed because you can only access it through the dayroom."

During an interview on 8/14/24 at 9:45 a.m. with Patient 13, Patient 13 stated patients have not been able to use the dayroom because "a patient destroyed it."

During an interview on 8/14/24 at 3 p.m. with Chief Executive Officer (CEO), CEO stated on 8/4/24, around 9:30 p.m., Patient 1 barricaded himself in the dayroom in unit 200. CEO stated Patient 1 was telling staff he couldn't sleep in his room and asked staff if he could hang out in the dayroom. CEO stated, "At some point, the staff walked away for a minute and [Patient 1] barricaded himself in the dayroom." CEO stated Patient 1 put chairs up against the door so staff couldn't come in and more staff were called in to assist. CEO stated, "within an hour he [Patient 1] had torn down the camera, ceiling tiles, some wiring, and broke glass in the main dayroom door." CEO stated local police were called, and took the Patient 1 into custody around 10:30 p.m.

During an interview on 8/18/24 at 10:30 p.m. with Registered Nurse (RN) 4, RN 4 stated, "I was the primary nurse taking care of [Patient 1] on 8/4/24 and right before 9 p.m., [Patient 1] was in the dayroom demanding food and stating he wanted to sleep in the dayroom. I told [Patient 1] the dayroom closes at 9 p.m. and patients must go to their rooms for the night." RN 4 stated, Patient 1 became upset and barricaded himself in the dayroom by putting chairs and a table in front of the door. RN 4 stated Patient 1 broke ceiling tiles, the camera, wires, a television, boxes on the wall, and broke glass out of the door. RN 4 stated the hospital called 911. RN 4 stated Patient 1 tried to cut himself with a piece of metal and was bleeding. RN 4 stated, "I've never seen anything like this, staff was scared, and one of our maintenance guys got punched in the face twice by [Patient 1] after he was called to try and get the door open." RN 4 stated Patient 1's provider was notified, and medications were ordered, but Patient 1 refused to let staff in the dayroom to give them. RN 4 stated local police eventually came in with force and arrested Patient 1. RN 1 stated the Administrator on call (AOC) came to the facility and was aware of the incident. RN 4 stated Patient 1 was considered a "harm to himself." RN 4 stated the dayroom and the patio has been closed ever since and patients are not allowed to use dayroom/patio.

During an interview on 8/19/24 at 9:48 a.m. with Plant Operations Maintenance Technician (POMT), POMT stated, on 8/4/24 around 9:30 p.m. he was asked by staff to help open a door where a patient had barricaded himself in the dayroom of unit 200. POMT stated Patient 1 had chairs and a table up against the door. POMT stated he pushed the door open a "little bit" and Patient 1 hit him in the face twice with his hand on the left side of his cheek. POMT stated he was scared of Patient 1 at this point and did not attempt to open the door anymore.

During a concurrent review of video surveillance and interview on 8/18/24 at 2 p.m. with Risk Manager (RM), CEO, and Chief Nursing Officer (CNO), the video surveillance dated 8/4/24 indicated, at:

9:15 p.m. - Patient closes the dayroom door and puts two chairs in front of the door. Staff seen at the door on the other side.
9: 28 p.m.- Seven staff members are gathered outside of the dayroom door. Patient 1 has four chairs and a table against the door inside the dayroom. Patient 1 is pacing the room and yelling at staff through the windows.
9:31 p.m.- Nine staff members are gathered outside of the dayroom door. Patient 1 is turning the lights on and off in the day room, yelling, and pacing the room.
9:45 p.m.- Eight local police officers arrive and gather outside dayroom door. One officer is seen trying to negotiate with Patient 1 through the windows.
9:47 p.m.- PMOT tries to open the door. Patient 1 hits PMOT in the face twice.
9: 52 p.m.- The dayroom camera is broken by Patient 1, only camera seen is outside of dayroom of staff and the police officers.
10:49 p.m.- Local police goes in dayroom and comes out with patient in handcuffs.

CEO stated she was made aware of this incident while it was happening.

During a review of Patient 1's, "Intake Assessment (IA)," dated 8/2/24, the "IA" indicated, Patient 1 was a moderate suicide risk. "[Patient 1] came on a 5150 [72 hour involuntary hold] stating he wanted to drive off a cliff."

During a review of Patient 1's, "High Risk Alert (HRA)," dated 8/2/24, the "HRA" indicated, Patient 1 was a high risk for suicide.

During a review of Patient 1's, "Physician Order (PO)," dated 8/3/24, the "PO" indicated, Patient 1 was on Suicide Precautions.

During a review of Patient 1's, "PO" dated 8/4/24, the "PO" indicated, Patient 1 was on Suicide Precautions.

During a review of Patient 1's, "Master Treatment Plan (MTP)," the "MTP" indicated, "Legal Status: Involuntary. Danger to self. Date Established 8/2/24."

During a review of Patient 1's "Nursing Progress Notes (NPN)," dated 8/4/24, the "NPN" indicated, "Around 21:00 [9 p.m.] during round time, staff request to all the patient's time to bed, we should close the dayroom [sic]. When staff members try to close the door and let's go to your room and take a rest then patient shut the door on staff [sic]. Staff told the patient [Patient 1] that you could not be in the dayroom passed 21:00 [9:00 p.m.] and explained to the patient that it is the policy of hospital. Patient [Patient 1] started yelling to the staff and he put all the furniture in front of the door. When staff try open to the door and patient keep yelling, staff tried to redirect him and, but he still barricaded himself in a dayroom [sic]. Around 21:10 [9:10 p.m.] NP called, and situation made aware. NP ordered Throazine 50 mg IM. Order carried by staff, patient refused to take medication [sic]. Patient [Patient 1] was violent, start punching wall. Pt [Patient 1] was hyperverbal, loud. For safety purpose Code Grey was announced at 2112 [ 9:12 p.m.]. Patient [Patient 1] still barricaded in the dayroom. Patient [Patient 1] was yelling [I wanted my discharge letter and I also want to listen to music and sleep in a dayroom. If I didn't get it, I will start hurting staff]. Staff began to start pushing dayroom door open. Patient [Patient 1] punched on the staff x 2. Patient was in very dangerous situation. He starts destroying hospital property. Pt [Patient 1] hit the window and broke the glasses and camera, also broke the grievance box and fire alarm box and also attempted cut self with metal piece. Pt [Patient 1] was barricaded in the room. Staff was not able to open the door. Situation was made aware to AOC and also NP as per ordered. At 2145 [9:45 p.m.] called to 911 for safety purpose for staff and also patient [Patient 1] was in dangerous situation inside the room. Patient [Patient 1] got on top of the table and began ripped ceiling out, camera and wires. Patient [Patient 1] took the camera out and attempted to brake [sic] the window again. Pt [Patient 1] also used metal panel to brake in dayroom gallery. Once the window was broken, He [Patient 1] reached into the broken window to open inside. Patient [Patient 1] then proceeded to take fridge out, water dispenser and cabinet door out of gallery and destroying property, Pt [Patient 1] was bleeding and licked it and put it on face [sic]. For follow up called 911 again because pt [Patient 1] was in a dangerous situation. Emergency staff states they are on the way to help him out. Patient [Patient 1] was still yelling on staff. Patient [Patient 1] was yelling out he did not care to die if cops got involved. He was going to go down with fight. Patient [Patient 1] continue destroying property, screaming and throwing item to door and windows until cops showed up. Cops showed up 2220 [10:22 p.m.] and cops were redirecting the patient but patient [Patient 1] was not cooperative and was saying on the cops and also yelling on the cops. For safety purpose cops broken off the door window reached inside the dayroom and patient escape in the gallery. Cops escort the patient at 2238 [10:38 p.m.] Patient was still aggressive towards staff and yelling on cops and staff."

During a review of the Hospital's Policy and Procedure (P&P) titled, "Rights & Responsibilities of Patient's and/or Parents", dated 2/22/22, the P&P indicated, "The rights and responsibilities delineated below apply to patients. . . All hospital personnel shall observe these patient rights. Patient Safety: The patient has the right to expect reasonable safety insofar [sic] as the hospital's practices and environment are concerned."

Based on interview and record review, the hospital failed to ensure that the face-to-face assessment for two of 30 sampled patients (Patient 3 and Patient 6) were completed within 1 hour of the initiation of the restraint (involuntary restricting the movement of arms or legs or the whole body) and seclusion (patient place alone in a quiet room being monitored by staff) for patients with violent and self-destructive behaviors. This failure resulted in patients' not receiving a comprehensive physical and behavioral assessment.

Findings:

During a concurrent interview and record review on 8/14/24 at 3 p.m. with Chief Nursing Officer (CNO), Patient 6's, "Restraint/Seclusion Orders for Violent Behavior (RSOVB)," dated 8/11/24 was reviewed. The RSOVB indicated Patient 6 was in seclusion on 8/11/24 at 2:15 p.m. and the face to face assessment was not documented. CNO stated the face to face assessment should be completed within one hour.

During a concurrent interview and record review on 8/15/24 at 10:40 a.m. with Registered Nurse (RN) 1, Patient 3's "RSOVB," dated 7/30/24 was reviewed. The RSOVB indicated, Patient 3 was in seclusion on 7/30/24 at 4:45 p.m. and the face to face assessment was not documented. RN 1 stated the face to face assessment should be completed within one hour.

During a concurrent interview and record review on 8/15/24 at 11 a.m. with RN 1, Patient 3's "RSOVB", dated 7/30/24 was reviewed. The RSOVB indicated, Patient 3 was in seclusion on 7/30/24 at 5:50 p.m. and the face to face assessment was not documented. RN 1 stated the face to face assessment should be completed within one hour.

During a review of the hospital's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 9/25/23, the P&P indicated, "The patient must be evaluated [face-to-face] as to the appropriateness of seclusion and restraint as an intervention within one (1) hour of the initiation of the intervention."

Based on interview and record review, the hospital failed to complete an admission assessment for one of 30 sampled patients (Patient 3). This failure had the potential to not meet Patient 3's mental health needs.

Findings:

During a concurrent interview and record review on 8/15/24 at 1:40 p.m. with Registered Nurse (RN) 1, Patient 3's "Nursing Admission Assessment (NAA)," dated 7/30/24 was reviewed. The NAA indicated all sections of the assessment were not completed. RN 1 stated the NAA was blank, and it should be completed after admission when the patient goes on the unit.

During a review of the hospital's policy and procedure (P&P) titled, "Nursing Service-Inpatient Mental Health Unit," dated 7/27/2022, the P&P indicated, "a. The Nursing Assessment shall be started in the first 8-hours of admission, and completed in 24-hours on cooperative patients. If the patient is uncooperative, the assessment shall be completed as soon as possible, and daily attempts to complete data areas should be made following admission. b. If patient remains uncooperative during the entire period, the assessment may be completed to the extent possible."

Based on observation, interview, and record review, the hospital failed to follow their Policy and Procedure (P&P) titled, "Occurrence Reporting & Adverse Event Determination" after one of eight sampled patients (Patient 1) was barricaded in a dayroom causing harm to himself and hospital staff. This failure resulted in the proper authorities not being notified of the incident and not being made aware of potential negative outcomes.

Findings:

During an interview on 8/14/24 at 11:47 a.m. with Risk Manager (RM), RM stated, the incident on 8/4/24 that involved Patient 1 barricading himself in the dayroom was not reported to the California Department of Public Health (CDPH). RM stated, "It is up to the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) what gets reported to CDPH. RM stated "They [CEO and CNO] let me know to report, then I send the paperwork to CDPH." RM stated she was aware of the incident and had also seen the video surveillance of the incident.

During a review of Patient 1's "Nursing Progress Notes (NPN)," dated 8/4/24, the "NPN" indicated, ". . . Staff told the patient [Patient 1] that you could not be in the dayroom passed 21:00 [9:00 p.m.] and explained to the patient that it is the policy of hospital. Patient [Patient 1] started yelling to the staff and he put all the furniture in front of the door. When staff try open to the door and patient keep yelling, staff tried to redirect him and, but he still barricaded himself in a dayroom [sic]. . . .Staff began to start pushing dayroom door open. Patient [Patient 1] punched on the staff x 2. Patient was in very dangerous situation. . . .Pt [Patient 1] also used metal panel to brake in dayroom gallery. Once the window was broken, He [Patient 1] reached into the broken window to open inside. . . Pt [Patient 1] was bleeding and licked it and put it on face [sic]. . ."

During an interview on 8/14/24 at 3 p.m. with CEO, CEO stated she did not report the incident to CDPH because "I didn't think it was reportable since nobody was injured, including patients, staff, or visitors and it isn't unusual for police officers to come onsite at our facility."

During an interview on 8/14/24 at 4:15 p.m. with CNO, CNO stated the incident on 8/4/24 with Patient 1 was not reported to CDPH. CNO stated, "we didn't think it needed to be reported."

During a concurrent interview and record review on 8/15/24 at 8:30 a.m. with RM, "Occurrence Summary Report (OSR)," dated 8/5/24 was reviewed. The OSR indicated, "[Patient 1] barricaded himself with multiple weighted table and chairs in the unit dayroom. The patient was yelling, threatening staff demanding to be discharged. Staff called a code Grey [patient escalation incident] to which additional staff members attended and provided verbal de-escalation and redirection. Despite staff's efforts, [Patient 1] began pulling down ceiling tiles which exposed wires he tugged on and broke off the surveillance camera. In addition, he [Patient 1] broke off the unit grievance box and hit the dayroom door windows causing them to break. Multiple attempts were made to de-escalate the patient [Patient 1] and contract for safety. [Local Police] was contacted to further assist in de-escalating the situation and prevent further property destruction caused by the patient [Patient 1]. The patient [Patient 1] was detained and taken into custody by local law enforcement." RM stated, "This [OSR] was done last night even though it is dated 8/5/24," RM stated, "it should have been done right after the incident occurred."

During a concurrent review of video surveillance and interview on 8/18/24 at 2 p.m. with RM, CEO, and CNO, the video surveillance dated 8/4/24 indicated, at:

9:15 p.m. - Patient closes the dayroom door and puts two chairs in front of the door. Staff seen at the door on the other side.
9: 28 p.m.- Seven staff members are gathered outside of the dayroom door. Patient 1 has four chairs and a table against the door inside the dayroom. Patient 1 is pacing the room and yelling at staff through the windows.
9:31 p.m.- Nine staff members are gathered outside of the dayroom door. Patient 1 is turning the lights on and off in the day room, yelling, and pacing the room.
9:45 p.m.- Eight local police officers arrive and gather outside dayroom door. One officer is seen trying to negotiate with Patient 1 through the windows.
9:47 p.m.- PMOT tries to open the door. Patient 1 hits PMOT in the face twice.
9: 52 p.m.- The dayroom camera is broken by Patient 1, only camera seen is outside of dayroom of staff and the police officers.
10:49 p.m.- Local police goes in dayroom and comes out with patient in handcuffs.

During an interview on 8/19/24 at 2:22 p.m. with CEO, CEO stated, after watching the video surveillance of the incident on 8/4/24, "an Unusual Occurrence Report should have been filed with CDPH."

During a review of the hospital's P&P titled, "Occurrence Reporting & Adverse Event Determination," dated 1/22/22, the P&P indicated, "Purpose: An effective Quality and Patient Safety Program requires optimal reporting of medical/healthcare occurrences. [Hospital] encourage recognition of risks to patient safety, the initiation of actions to reduce these risks, the internal reporting of what has been found and the actions taken to avoid reoccurrence. The focus is to be on improving processes and systems and to discourage individual blame or retribution for involvement in a medical/healthcare care occurrence. The Director of Quality/Risk/compliance has been designated by the Governing Board to ensure ongoing compliance with required notifications to the Office of Licensing and Certification, State of California. . . Policy: 1. Under the direction of the Chief Executive Officer, The Director of Quality/Risk/Compliance is responsible to ensure prompt notification to CDPH, when indicated, as required by applicable regulations related to the hospital license. 4. It is the responsibility of all hospital staff to report occurrences. . . In the event that an occurrence meets the self-reporting provision in title 22. . . the Director of Quality/Risk/Compliance or their designee will report no later than 5 days after the event has been detected; or, if the event is on ongoing urgent or emergent threat to the welfare, health, or safety of patients, personnel, or visitors, no later than twenty-four [24] hours after the adverse event has been detected. Unusual Occurrences may include but is not limited to: Epidemic outbreak, poisoning, fire, major accident, disaster, and other catastrophe or other unusual occurrence which threatens the welfare, safety, or health of patients, personnel, or visitors."

Based on interview and record review, the hospital failed to ensure prescriptions were sent to a pharmacy after discharge from the facility for one of 30 sampled patients (Patient 2). This failure resulted in Patient 2 not having medications he required daily which had the potential for adverse affects and withdrawals.

Findings:

During a concurrent interview and record review on 8/19/24 at 10 a.m. with Risk Manager (RM), Patient 2's, "Discharge Aftercare Plan (DAP)," dated 7/8/24 was reviewed. The DAP indicated, "Pharmacy [Patient 2's Pharmacy], Pharmacy Contact: E [Electronic]-Prescriptions, Signature by Patient 2, Signature by two Registered Nurse's." RM stated this form is filled out to indicate that medications Patient 2 will take after discharge will be sent electronically to the pharmacy listed.

During a concurrent interview and record review on 8/19/24 at 10:15 a.m. with RM, Patient 2's, "Discharge Medication Summary for Patient (DMS)," (undated) was reviewed. The DMS indicated, no medications were electronically sent to Patient 2's pharmacy after discharge. RM stated two different medications were supposed to be sent to Patient 2's pharmacy for continued use after discharge from the facility.

During a concurrent interview and record review on 8/19/24 at 10:23 a.m. with RM, Patient 2's, "Medication Administration Report (MAR)," dated 7/8/24 was reviewed. The MAR indicated, Abilify [medication used to treat mental health disorders] 10 mg [milligram] take one tablet at bedtime. Depakote [medication used to treat mood disorders] 500 mg take one tablet at bedtime. Physician wrote "continue" beside each medication and signed the bottom of the MAR. RM stated this is what the facility reviews to see what medications should be electronically sent to Patient 2's pharmacy upon discharge from our facility. RM stated this did not happen and Patient 2 did not have any medications sent electronically to the pharmacy.

During a review of the hospital's policy and procedure (P&P) titled, "Discharge of Patients," dated 7/27/22, the P&P indicated, "Purpose: To ensure a smooth transition to the next level of care and to ensure continuity of the treatment modalities selected for the patient. Documentation: Ask physician if they wish to have medications called to the pharmacy for the patient."

Based on observation, interview, and record review, the hospital failed to ensure patient centered therapeutic activities were followed per posted "Weekly Activities Schedule (WAS)" for nine of 30 sampled patients (Patient 3, Patient 4, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This failure had potential to negatively impact patient's psychosocial well-being and not meet psychological needs.

Findings:

During a concurrent observation and interview on 8/14/24 at 9:30 a.m. with Risk Manager (RM) in unit 200, dayroom was closed and there were eight chairs in the hallway and no therapy/activity happening. RM stated, there is no activity going on at this time.

During a concurrent observation and interview on 8/14/24 at 10:25 a.m. with RM in unit 200, there was no therapy group happening. Patients were observed sleeping in their rooms and walking in the hallway. RM stated there is no therapy group going on at this time.

During an interview on 8/14/24 at 10:40 a.m. with Patient 4, Patient 4 stated since she has been at the facility, she has not been offered any activities.

During a concurrent observation and interview on 8/14/24 at 11 a.m. with Registered Nurse (RN) 2 in Unit 200 hallway, there was no therapy group happening with the patients. RN 2 stated therapy group did not happen this morning.

During an interview on 8/14/24 at 11:10 a.m. with RN 3, RN 3 stated patients have not been doing patio time for the last six days. RN 3 stated "Not having therapy is affecting mental health, but I am not sure how."

During an interview on 8/14/24 at 11:20 a.m. with Social Service Director (SSD), SSD stated the therapist who was supposed to be doing therapy group in unit 200 today, scheduled herself for another training and did not update him on the schedule conflict. SSD stated his expectations are for the activity schedule to be followed. SSD stated, "Recreational therapy should be offered. No Fresh air is being done. It is detrimental."

During a review of the unit's "Adult Activity Schedule (AAS)," (undated), the "AAS" indicated, "Activity Group is from 9 a.m.-10 a.m., Therapy Group is from 10 a.m. - 11 a.m., 2nd Activity Group is from 1 p.m.- 2 p.m., and 2nd Therapy Group is 2 p.m.- 3 p.m."

During a concurrent observation and interview on 8/14/24 at 2:20 p.m. with Mental Health Worker (MHW) 1, in Unit 200, group therapy was not happening. MHW 1 stated patients did not get their fresh air break, activity group from 1 p.m.-2 p.m., and no therapy group from 2 p.m.-3 p.m.

During a concurrent interview and record review on 8/15/24 at 8:30 a.m. with RM, Patient 11's, "Group Notes (GN)", 7/31/24- 8/5/24 was reviewed. The GN indicated, Patient 11 did not receive group therapy/activities on:

7-31-24 at 2 p.m.- 3 p.m.
8-1-24 at 10 a.m.- 11 a.m.
8-5-24 at 9 a.m.- 10 a.m.
8-5-24 at 10 a.m.- 11 a.m.
8-5-24 at 1 p.m.- 2 p.m.

RM stated, "that means he [Patient 11] didn't get any activities or therapy during those times."

During a concurrent observation and interview on 8/15/24 at 8:40 a.m. with RM in unit 200, chairs were being moved from hallway to dayroom. No activities were happening. RM stated dayroom should be open within the one hour. RM stated patients will miss activities until 10 a.m.

During a concurrent interview and record review on 8/15/24 at 11:50 a.m. with RN 1, Patient 3's "GN," dated 8/5/24 was reviewed. The GN indicated, Patient 3 did not receive therapy or activities from 8:30 a.m.- 2 p.m. RN 1 stated there is no documentation confirming Patient 3 received therapy or activities 8:30-2 p.m. RN 1 stated "If it is not documented it is not done."

During a concurrent interview and record review on 8/15/24 at 2:50 p.m. with RN 1, Patient 7's "GN," dated 8/7/24-8/12/24 was reviewed. The GN indicated, Patient 7 did not receive group therapy/activities on:

8/7/24 at 1 p.m. - 2 p.m. and 2 p.m. - 3 p.m.,
8/8/24 at 2 p.m.- 3 p.m.,
8/9/24 at 1 p.m. - 2 p.m.
8/10/24 at 2 p.m. - 3 p.m.

RN 1 stated there is no documentation that Patient 7 had group therapy/activities for the above dates and times.

During a concurrent interview and record review on 8/15/24 at 3:10 p.m. with RN 1, Patient 8's, "GN", dated 8/1/24-8/7/24 were reviewed. The GN indicated, Patient 8 did not receive group therapy/activities on:

8/5/24 at 9a.m. -10 a.m., 10 a.m.-11 a.m., 12 p.m.-1 p.m., 1 p.m.-2 p.m.
8/6/24 at 2 p.m. - 3 p.m.

RN 1 stated there is no documentation that Patient 8 had group therapy/activities for the above dates and times.

During a current interview and record review on 8/19/24 at 10:06 a.m. with Chief Nursing Officer (CNO), Patient 4's, "GN", dated 8/14/24 was reviewed. The GN indicated, Patient 4 did not receive group therapy/activities on:

8/14/24 at 9 a.m.-10 a.m., 10 a.m.- 11 a.m.

CNO stated there is no documentation that Patient 4 had group therapy/activities for the above date and times.

During a current interview and record review on 8/19/24 at 10:30 a.m. with CNO, Patient 9's, "GN", dated 8/14/24 was reviewed. The GN indicated, Patient 9 did not receive group therapy/activities on:

8/14/24 at 9 a.m.-10 a.m., 1 p.m.-2 p.m.

CNO stated there is no documentation that Patient 9 had group therapy/activities for the above date and time.

During a current interview and record review on 8/19/24 at 10:40 a.m. with CNO, Patient 10's, "GN," dated 8/18/24 was reviewed. The GN indicated, Patient 10 did not receive group therapy/activities on:

8/18/24 at 9 a.m.-10 a.m., 10 a.m.-11 a.m., and 1 p.m.-2 p.m.

CNO stated there is no documentation that Patient 10 had group therapy/activities for the above date and times.


42148

During a concurrent interview and record review on 8/19/24 at 10:47 a.m. with RM, Patient 5's, "GN", dated 8/14/24-8/15/24 was reviewed. The GN indicated, Patient 5 did not receive group therapy/activities on:

8-14-24 at 9 a.m.-10 a.m., 10 a.m.- 11 a.m., and 2 p.m.-3 p.m.

8-15-24 at 2 p.m.- 3 p.m..

RM stated there is no documentation that Patient 5 had group therapy/activities for the above dates and times.

During a concurrent interview and record review on 8/19/24 at 11 a.m. with RM, Patient 12's, "GN", dated 8/13/24-8/14/24 was reviewed. The GN indicated, Patient 12 did not receive group therapy/activities on:

8-13-24 at 1 p.m.- 2 p.m.

8-14-24 at 10 a.m., 1 p.m. - 2 p.m., 2 p.m. - 3 p.m.

RM stated there is no documentation that Patient 12 had group therapy/activities for above dates and times.

During a review of the hospital's policy and procedure (P&P) titled, "Therapeutic Group Intervention," dated 4/27/22, the P&P indicated, "A formalized group schedule has been developed and is posted in each of the units for staff to follow. Each discipline is scheduled and required to provide group sessions at a designated time throughout the day."