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Based on interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:

1. The facility failed to develop and implement a treatment care plan (provides a framework for evaluating and providing patient care needs related to the treatment process including discharge planning) for one of 30 sampled patients (Patient 2) to ensure that Patient 2 was safely discharged from the facility in accordance with the facility's policy and procedure regarding treatment care plan and discharge planning (the process of identifying and preparing for a patient's anticipated health care needs after they leave the hospital). Patient 2 (who was a conserved [when another person has authority over another person based on a court decision made by a judge] patient) was discharged on 11/4/2023 without the facility notifying Patient 2's Public Guardian (court appointed representative for Patient 2). Patient 2's whereabouts remained unknown post discharge.

This deficient practice resulted in Patient 2's discharge planning goals not being met by not identifying the patient's needs and risks post discharge. This deficient practice also had the potential to put Patient 2 at risk for injury and/or death since Patient 2 was diagnosed as danger to self (if a person is unable to care for himself or puts himself in a position of danger or is likely to suffer harm), thus requiring a Public Guardian. (Refer to A-0396).

2. The facility failed to ensure two of 30 sampled patients (Patient 1 and Patient 7) received medication treatment (Antibiotic topical ointment [used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns] and Prazosin [medication to treat high blood pressure]) as ordered by the physician in accordance with the facility's policy and procedure regarding medication administration. Patient 1 did not receive the antibiotic topical ointment for seven days and Patient 7 did not receive Prazosin for 10 days.

This deficient practice had the potential for Patient 1's lacerations (cut in the skin) to develop infection and remain untreated as well as for Patient 7's hypertension (high blood pressure) to get worse which may prolong both patients' (Patient 1 and Patient 7) hospitalization. (Refer to A-0398)

3. The facility failed to ensure an incident of alleged abuse (intentional maltreatment of an individual that may cause physical or psychological injury) involving one of 30 sampled patients (Patient 1) was reported to the Department within the required timeframe (within 24 hours) in accordance with the facility's policy and procedure regarding mandated reporting for abuse.

This deficient practice had the potential to leave Patient 1 in an unsafe environment due to delay of investigation which may result in patient harm and/or death. (Refer to A-0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment. These deficient practices also placed the patients' health and safety at risk by not reporting an alleged abuse incident in a timely manner (within 24 hours) and by not ensuring the safe discharge of a conserved patient.


On 11/30/2023 at 5:35 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Facility Executive Director Quality Risk and PI (Performance Improvement and the Manager for PI/Quality Management. Patient 2 was admitted on a 5150 hold (involuntary detention of a patient for 72 hours for a psychiatric [mental, emotional and behavioral conditions] evaluation and treatment) for being a danger to self (DTS), on 10/29/2023 at 6:30 p.m. in the Behavioral Health Unit (area of the hospital designed to stabilize a patient with a mental health emergency). The facility's Social Worker (SW 1) was contacted by Patient 2's Public Guardian, who was the court's appointed representative for Patient 2, on 10/30/2023 at 3:40 p.m. regarding Patient 2's status. The facility failed to safely discharge Patient 2, who was conserved (when another person has authority over another person based on a court decision made by a judge) by a Public Guardian by: 1. Not updating the patient ' s (Patient 2) information legal status on patient medical records that Patient 2 was conserved. 2. SW 1 received the notification, on 10/30/203, that Patient 2 was conserved and did not report to the interdisciplinary team (nurses, discharge planner, physician, and case manager). 3. Patient 2's interdisciplinary (IDT- comprise of the attending psychiatrist, nursing, discharge planners, etc.) note, dated 10/31/2023 indicated, Patient 2 was going to be discharged home independently, no conservatorship status (when a judge appoints another person to act or make a decision for the person who needs help) was recorded in the note. 4. According to facility policy and procedure for Social Services, the social worker will be paired with a discharge planner. Both are required to review the notes from their counterpart daily. The discharge planner did not review the social worker's note regarding Patient 2 being conserved on 10/20/2023. This deficient practice has resulted in Patient 2 being discharged without notification to the Public Guardian and Patient 2's whereabouts remained unknown.

On 12/1/2023 at 4:23 p.m., the IJ was removed in the presence of the Facility Executive Director Quality Risk and PI (Performance Improvement and the Manager for PI/Quality Management after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ removal plan indicated updates/revision of the facility's policy and procedures regarding "Discharge Planning/Guidelines," "Social Services Policy," and "Multidisciplinary treatment Plan (treatment plan involving different disciplines such as nursing, social work, attending psychiatrist, etc.)." The revised policies included the following updates: 1. Social Work will coordinate with discharge planning on conservator status (when a judge appoints another person to act or make a decision for the person who needs help) 2. Discharge planner will review the social work discharge assessment for concurrence within 24 hours of completion 3. Social work will coordinate with discharge planning on conservator status. 4. Mandatory attendance of nursing, social work, discharge planning, recreational therapy, the attending psychiatrist and the patient (if possible) at both the initial and weekly treatment team meetings to ensure all care team members communicate and develop a plan of care and safe discharge plan. The IJ removal plan also included education and competency assessment validation for social workers and discharge planners which began 12/1/2023 until 12/6/2023.

Based on interview and record review, the facility failed to develop and implement a treatment care plan (provides a framework for evaluating and providing patient care needs related to the treatment process including discharge planning) for one of 30 sampled patients (Patient 2) to ensure that Patient 2 was safely discharged from the facility in accordance with the facility's policy and procedure regarding treatment care plan and discharge planning (the process of identifying and preparing for a patient's anticipated health care needs after they leave the hospital). Patient 2 (who was a conserved [when another person has authority over another person based on a court decision made by a judge] patient) was discharged on 11/4/2023 without the facility notifying Patient 2's Public Guardian (court appointed representative for Patient 2). Patient 2's whereabouts remained unknown post discharge.

This deficient practice resulted in Patient 2's discharge planning goals not being met by not identifying the patient's needs and risks post discharge. This deficient practice also had the potential to put Patient 2 at risk for injury and/or death since Patient 2 was diagnosed as danger to self (if a person is unable to care for himself or puts himself in a position of danger or is likely to suffer harm), thus requiring a Public Guardian.

On 11/30/2023 at 5:35 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Facility Executive Director Quality Risk and PI (Performance Improvement and the Manager for PI/Quality Management. Patient 2 was admitted on a 5150 hold (involuntary detention of a patient for 72 hours for a psychiatric [mental, emotional and behavioral conditions] evaluation and treatment) for being a danger to self (DTS), on 10/29/2023 at 6:30 p.m. in the Behavioral Health Unit (area of the hospital designed to stabilize a patient with a mental health emergency). The facility's Social Worker (SW 1) was contacted by Patient 2's Public Guardian, who was the court's appointed representative for Patient 2, on 10/30/2023 at 3:40 p.m. regarding Patient 2's status. The facility failed to safely discharge Patient 2, who was conserved (when another person has authority over another person based on a court decision made by a judge) by a Public Guardian by: 1. Not updating the patient's (Patient 2) information legal status on patient medical records that Patient 2 was conserved. 2. SW 1 received the notification, on 10/30/203, that Patient 2 was conserved and did not report to the interdisciplinary team (nurses, discharge planner, physician, and case manager). 3. Patient 2's interdisciplinary (IDT) note, dated 10/31/2023 indicated, Patient 2 was going to be discharged home independently, no conservatorship status (when a judge appoints another person to act or make a decision for the person who needs help) was recorded in the note. 4. According to facility policy and procedure for Social Services, the social worker will be paired with a discharge planner. Both are required to review the notes from their counterpart daily. The discharge planner did not review the social worker's note regarding Patient 2 being conserved on 10/20/2023. This deficient practice has resulted in Patient 2 being discharged without notification to the Public Guardian and Patient 2's whereabouts remained unknown.

On 12/1/2023 at 4:23 p.m., the IJ was removed in the presence of the Facility Executive Director Quality Risk and PI (Performance Improvement and the Manager for PI/Quality Management after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ removal plan indicated updates/revision of the facility ' s policy and procedures regarding "Discharge Planning/Guidelines," "Social Services Policy," and "Multidisciplinary treatment Plan (treatment plan involving different disciplines such as nursing, social work, attending psychiatrist, etc.)." The revised policies included the following updates: 1. Social Work will coordinate with discharge planning on conservator status (when a judge appoints another person to act or make a decision for the person who needs help) 2. Discharge planner will review the social work discharge assessment for concurrence within 24 hours of completion 3. Social work will coordinate with discharge planning on conservator status. 4. Mandatory attendance of nursing, social work, discharge planning, recreational therapy, the attending psychiatrist and the patient (if possible) at both the initial and weekly treatment team meetings to ensure all care team members communicate and develop a plan of care and safe discharge plan. The IJ removal plan also included education and competency assessment validation for social workers and discharge planners which began 12/1/2023 until 12/6/2023.

Findings:

During a review of Patient 2's "History and Physical (H&P- a formal and complete assessment of the patient and the problem)," dated 10/30/2023, the "H&P" indicated, Patient 2 was admitted to the facility on a 5150 hold (a 72-hour psychiatric [mental, emotional and behavioral conditions] hospitalization, an involuntarily detention of an adult who is experiencing a mental health crisis when evaluated to be a danger to others [if a person is likely to perform an act intentionally or unintentionally to others and such act maybe either violent or nonviolent], or to himself or herself, or gravely disabled [a condition in which a person, as a result of mental disorder, is unable to provide for his or her basic personal needs for food, clothing, and shelter) for danger to self (if a person is unable to care for himself or puts himself in a position of danger or is likely to suffer harm).

During a review of Patient 2's medical record, titled "Social Services Progress Note," dated 10/30/2023, the Social Services Progress note indicated, Social Worker (SW 1) was contacted by Patient 2's Public Guardian (PG, court appointed representative for Patient 2) to find out about Patient 2's well-being. The note further indicated, SW 1 documented PG's contact information and was aware of conserved status (when another person has authority over another person based on a court decision made by a judge) of Patient 2.

However, the SW 1 did not communicate Patient 2's conservatorship status to the Discharge planner in order to have the master treatment care plan updated with the patient's legal status. Likewise, the Discharge Planner, who participates in the interdisciplinary team meeting, to discuss the treatment care plan (provides a framework for evaluating and providing patient care needs related to the treatment process), did not review the Social worker ' s notes regarding Patient 2's conservatorship status. This information was verified by the Director of Behavioral Health Unit (DBHU 2).

During a review of Patient 2's Interdisciplinary (care team comprised of the attending psychiatrist, nursing, discharge planner, etc.) treatment care plan, dated 10/31/2023, the treatment care plan indicated, the treatment team participating in Patient 2's discussion of treatment and discharge planning needs, did not include a social worker present during the meeting. The documentation further indicated, nursing created the treatment care plan and signed off on the information discussed during the meeting. The treatment care plan also indicated, nursing did not review the SW 1's note, dated 10/30/2023, where the SW 1 documented that Patient 2 was conserved. Therefore, the information regarding Patient 2's conserved status was not included in the treatment care plan which was prepared by nursing.

During further review of Patient 2's medical record, dated 10/30/2023 to 11/4/2023, Patient 2's medical record did not contain any reference to Patient 2's conserved status, no further follow up or documentation of any communication with Patient 2's Public Guardian was done or documented, and there was no documentation of inclusion of Patient 2's Public Guardian in discharge planning (the process of identifying and preparing for a patient's anticipated health care needs after they leave the hospital), and there is no mention of the patient's conservatorship in the treatment care plan to ensure that everyone is aware about the patient's conservatorship status in preparation for a safe discharge specific to Patient 2's needs and risks. This lack of documentation or updates in Patient 2's treatment care plan was verified by the facility's Director of Behavioral Health Unit (DBHU 2).

During a review of Patient 2's Discharge Summary (a summary of the patient's health journey during their hospital stay including their initial condition, progress, treatment responses, and health status at discharge), dated 11/04/2023, the Discharge Summary indicated Patient 2 was discharged to own resources/self-care on 11/04/2023.

During an interview with Patient 2's Public Guardian (PG), on 11/27/2023 at 9:33 a.m., the PG stated, the whereabouts of Patient 2 remained unknown until 11/27/2023 (during the time of the interview).

During a concurrent interview and record review on 11/29/2023 at 9:53 a.m. with the director of Behavioral Health Unit (DBHU 2) and the Discharge Planner (DP 1) Patient 2's medical record (MR), dated 10/30/2023 to 11/4/2023, was reviewed. The MR indicated, on 10/30/2023, Patient 2 was admitted on a 5150 hold for being a danger to self (DTS). The MR further indicated, on 10/30/2023, the Social Worker (SW 1), documented being contacted by Patient 2's Public Guardian (PG) to check how Patient 2 was doing. No further follow up by SW 1 in regard to Patient 2's conservatorship status was documented or found in Patient 2's medical chart. No copy of Patient 2's conservatorship documents was uploaded in Patient 2's chart. This finding was verified by the DBHU2 and the DP 1. Patient 2's interdisciplinary (IDT) note (a note containing documentation of all members of the treatment team [interdisciplinary team consisting of a charge nurse, primary nurse, social worker, discharge planner and a physician]), dated 10/31/2023 indicated, Patient 2 was going to be discharged home independently, no conservatorship status was recorded in the note.

The MR further indicated, on 11/3/2023, SW 1 documented, Patient 2 continued to remain on a 14-day hold (involuntary detention of a patient for psychiatric treatment as mandated by a court). DBHU 2, stated, a patient who is conserved by a Public Guardian should not be placed on an extended hold due to patient's conserved status requiring the legally appointed Public Guardian to make psychiatric medical decisions on patient's behalf regarding patient treatment, discharge, and placement. The DP 1 stated, Patient 2's discharge plan had to be coordinated with Patient 2's PG because conserved patients cannot be safely discharged to self when conserved by a Public Guardian because such patients are unable to properly care for themselves and or make safe decisions about personal safety and well-being.

During an interview, on 11/29/2023 at 10:09 a.m. with social worker (SW 2), SW 2 stated, when the facility became aware of Patient 2's unsafe discharge, the investigation showed, the SW 1 received the required conservatorship documents for Patient 2. However, SW 1 failed to upload the received legal documentation. In addition, SW 1 continued to document as if Patient 2 was on a 14-day psychiatric hold and had no legal conservator. Likewise, SW 1 failed to communicate with the care team (comprised of the attending psychiatrist, nursing, discharge planner, etc. who are involved in the care of the patient) the legal conservatorship status of Patient 2. SW 2 further stated SW 1 was terminated due to negligence because it was solely the social worker's responsibility to obtain the conservatorship documents and communicate with the rest of the care team.

During an interview on 11/29/2023 at 10:40 a.m., with discharge planner (DP 1), the DP 1 stated, updating legal status of a patient, especially the conservatorship information, is a responsibility of a social worker and the expectation is for the social worker to do the job. The DP 1 further stated, the discharge planners do not regularly read social worker's notes.

During an interview, on 11/30/2023 at 10:16 a.m. with the Director of Case Management (DCM), the DCM stated, the social worker's job responsibility includes obtaining the conservatorship documents and communicating information with the rest of the care team. The DCM further stated, the expectation of the care team is to communicate effectively, especially the status of conserved patients as they have different discharge pathway (process of discharging a patient) and cannot be discharged without a safe plan discussed with a conservator or with a Public Guardian. DCM further stated, every patient has a social worker and a discharge planner on their case, they work in the same department and share similar responsibilities; and the expectation is for them to communicate effectively and read each other's notes. The DCM further stated, the expectation of reading patient's chart applies to all care team members, and all must read each other's notes because this is what they are trained to do.

During a review of the facility's policy and procedures (P&P) titled, "Admission Assessment," dated 10/2021, the P&P indicated, "All patients admitted to the Behavioral Health Unit (area of the hospital designed to stabilize a patient with a mental health emergency) must have legal status assessment completed to determine a legal history and a preliminary discussion to determine how much the patient ' s legal situation will influence their progress in treatment and the urgency of the legal situation, discharge planning needs and assessment."

During a review of the facility's policy and procedure (P&P) titled "Social Services," dated 10/2021, the P&P indicated, "It is the policy of the Behavioral Health Unit to collaborate with the Social Service Department to provide a continuum of patient care in relation to the psychosocial, legal and discharge planning needs of patients in the Unit. Social Service staff performs a comprehensive assessment of the patient that addresses the patient's social, emotional, functional and legal status. Based on this assessment, treatment and discharge planning needs are identified. Social Service Staff are also a liaison to ensure that the patient's legal needs are handled in a timely manner. Social Service Staff are a part of the interdisciplinary team (comprise of the attending psychiatrist, nursing, social services, discharge planners, etc.) and provide pertinent information to nursing and physician staff regarding the patient."

During a review of the facility's policy and procedure (P&P) titled "Conservatorship," dated 10/2021, the P&P indicated," If the Conservatee (a person deemed incompetent by a court) is under Public Guardianship, Behavioral Health Unit (BHU) staff will call the office of the Public Guardian immediately after admission to verify Conservatorship (when a judge appoints another person to act or make a decision for the person who needs help) and obtain treatment consent. The nurse must document in the Conservatee's chart the person with whom the staff member spoke, Conservatorship court number, and expiration date."

During a review of the facility's policy and procedures (P&P) titled, "Multidisciplinary (comprise of the attending psychiatrist, nuraing, social services, discharge planners, etc.) Treatment Plan," dated 10/2021, the P&P indicated, "Each patient admitted to the BHU shall have an individualized written treatment plan which is based on interdisciplinary clinical assessments, beginning at the time of admission and continuing through discharge. Each discipline (medical, nursing, social and behavioral services, case management, and adjunct therapy [therapy given in addition to the main treatment to maximize its effectiveness) must assess the patient, address problems on the master problem list by writing interventions to be utilized by the specific discipline and should include specific discharge criteria necessary for the patient to achieve and maintain stability as deemed appropriate for the patient's capabilities."

During a review of the facility's policy and procedures (P&P) titled, "Multidisciplinary Treatment Plan," dated 10/2021, the P&P indicated, "The treatment planning takes place prior to the first treatment team meeting for the patient and is reviewed at the first treatment meeting and in regular reviews."

During a review of the facility's policy and procedure (P&P) titled "Discharge Planning," dated 10/2021, the P&P indicated, "Discharge planning is an organized, coordinated with the disciplinary treatment team process in order to meet the unique and individualized needs of the patient..."

Based on interview and record review, the facility failed to ensure:

1. Two of 30 sampled patients (Patient 1 and Patient 7) received medication treatment (Antibiotic topical ointment [used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns] and Prazosin [medication to treat high blood pressure]) was administered as ordered by the physician in accordance with the facility's policy and procedure regarding medication administration. Patient 1 did not receive the antibiotic topical ointment for seven days and Patient 7 did not receive Prazosin for 10 days.

This deficient practice had the potential for Patient 1's lacerations (cut in the skin) to develop infection and remain untreated as well as for Patient 7's hypertension (high blood pressure) to get worse which may prolong both patients' (Patient 1 and Patient 7) hospitalization.

2. An incident of alleged abuse (intentional maltreatment of an individual that may cause physical or psychological injury) involving one of 30 sampled patients (Patient 1) was reported to the Department within the required timeframe (within 24 hours) in accordance with the facility's policy and procedure regarding mandated reporting for abuse.

This deficient practice had the potential to leave Patient 1 in an unsafe environment due to delay of investigation which may result in patient harm and/or death.

Findings:

1a. During a review of Patient 1's "History and Physical (H&P- a formal and complete assessment of the patient and the problem)" dated 7/12/2022, the H&P indicated Patient 1 was admitted to the facility for depression (a mental disorder which involves loss of pleasure or interest in activities for long periods of time), psychosis (a mental disorder in which people have trouble distinguishing between what is real and what is not), and danger to self (if a person is unable to care for himself or puts himself in a position of danger or is likely to suffer harm). The "H&P" also indicated that Patient 1 had multiple wounds and cellulitis (infection of skin).

During a review of Patient 1's physician order dated 7/12/2022, the order indicated Triple Antibiotics topical ointment (used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns) to be applied to bilateral (both) forearms and left thigh superficial lacerations (cut in the skin) twice a day for 7 days starting 7/12/2022.

During a concurrent interview and record review on 11/28/2023 at 11:19 a.m. with Performance Improvement RN (RN 8), Patient 1's "Medication Administration Record (MAR)" from 7/12/2022 to 7/18/2022 was reviewed. The MAR indicated, the Triple Antibiotic topical ointment was recorded as "not done due to equipment/supplies unavailable" on 7/12/2022 p.m. shift, 7/13/2022 a.m. shift and p.m. shift, 7/14/2022 p.m. shift, 7/15/2022 a.m. shift and p.m. shift, 7/16/2022 a.m. shift and p.m. shift, 7/17/2022 a.m. shift and p.m. shift, 7/18/2022 a.m. shift and p.m. shift. RN 8 stated the medication was not given for 7 days because it was not available per MAR. Likewise, the RNs assigned to Patient 1 did not call the pharmacy to follow-up on the missing medication (antibiotic topical ointment). The RNs just documented that the medication (antibiotic topical ointment) was unavailable.

During an interview on 11/28/2023 at 3:38 p.m. with Director of Behavioral Health (DBHU2), DBHU2 stated if medication is not available, nurse should call Pharmacy to deliver the medication. DBHU2 stated, "it ' s doctor order and we need to follow up." DBHU2 further stated the patient could decompensate (deteriorate or worsen) and wound could potentially get worse and get infected if treatment was not done.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 11/2021, the P&P indicated, "Pharmacy will deliver the new medications to the nursing unit. Nursing has the option of picking medications up from Pharmacy."

1b. During a review of Patient 7's "History and Physical (H&P- a formal and complete assessment of the patient and the problem)" dated 6/8/2023, the "H&P" indicated Patient 7 was admitted to the facility for acute respiratory distress (a serious lung condition that is caused by low blood oxygen), accelerated hypertension (high blood pressure), and depression (a mental health disorder characterized by loss of interest in activities which causes significant impairment in daily life).

During a concurrent interview and record review on 11/29/2023 at 12:07 p.m. with Licensed Vocational Nurse (LVN 2), Patient 7's "Medication Administration Record (MAR)" from 11/18/2023 to 11/27/2023 was reviewed. The MAR indicated, the Prazosin (medication to treat high blood pressure) 1 milligram (mg- a unit of measurement) at bedtime to be given by mouth for 30 days starting 10/23/2023 was recorded as "not done due to patient refused" on 11/18/2023, 11/19/2023, 11/20/2023, 11/21/2023, 11/22/2023, 11/23/2023, 11/24/2023, 11/25/2023, 11/26/2023 and 11/27/2023. LVN 2 stated the medication was not given for 10 days because of patient refusal per MAR. LVN 2 said nurse should notify physician if the patient refused to take the medication and document in the nurses notes. LVN 2 further stated that there was no documentation indicating communication with physician about patient's (Patient 7) refusal of Prazosin.

During a review of Patient 7's Vital signs (temperature, blood pressure, heart rate, respiratory rate) record on 11/29/2023 at 12:07 p.m., the Vital signs record indicated that from 11/18/2023 to 11/27/2023, when Patient 7 was refusing to take his (Patient 7) Prazosin medication for blood pressure maintenance, Patient 7's systolic blood pressure (measures the pressure in the arteries when the heart beats) range was from 150 to 184 millimeters of mercury (mmHg- a unit of measurement; any systolic blood pressure above 130 mmHg is considered hypertensive [high blood pressure]).

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 11/2021, the P&P indicated, "when medications eligible for a scheduled dosing time are not administered within the defined time period, the nurse will notify the prescribing/ attending physician ... the physician is to be notified of all refused medications."

2. During a review of Patient 1's "History and Physical (H&P - a formal and complete assessment of the patient and the problem)" dated 7/12/2022, the H&P indicated Patient 1 was admitted to the facility for depression (a mental disorder involves loss of pleasure or interest in activities for long periods of time), psychosis (a mental disorder that people have trouble distinguish between what is real and what is not), and danger to self.

During a review of Patient 1's "Progress Notes Non-Physician (nurses notes)," dated 7/15/2022 at 4:02 p.m., the nurses notes indicated "bruises noted under both eyes with bright redness to left eye. When asked what happened he states, 'I got beat up by staff.' Charge nurse notified."

During a review of Patient 1's nurses notes dated 7/16/2022 at 10:38 p.m., the nurses notes indicated the Police Department arrived at the facility for investigation and the physician was aware of bruises on Patient 1's both eyes and ordered computed tomography scan of head without contrast (CT scan, an imaging test to help diagnose internal injuries and disease providing cross-sectional images of bones, blood vessels and soft tissues inside the body).

During a review of Patient 1's "CT Brain without contrast report (CT report)," dated 7/18/2022 with addendum added on 8/19/2022, the CT report indicated, "Right orbital floor fracture (there is a break in one of the bones surrounding the eyeball) with displacement of 4 millimeters (mm- a unit of measurement) is identified of questionable age."

During a review of the facility's "Report of Adverse Event/Unusual Occurrence" report, dated 7/25/2022, the report indicated the date event of discovery of incident was 7/20/2022. However, the facility submitted the report to CDPH only on 7/26/2022 (6 days from the recorded date of discovery [7/20/2023] and 11 days from the day that Patient 1 reported the alleged assault to the nursing staff (7/15/2023]).

During an interview on 11/28/2023 at 1:16 p.m. with Director of Quality (DQ), DQ stated alleged assault (when someone inflicts physical contact that causes bodily harm and/or injury to another individual) qualified for adverse event (event in which care resulted in an undesirable outcome) and it should be reported to the Department within 5 days.

During an interview on 11/29/2023 at 3:05 p.m. with Director of Quality (DQ), DQ stated nurse reported Patient 1 ' s alleged assault on 7/15/2022 in the afternoon but Quality department did not investigate until 7/20/2022. DQ said, "it was a delay on our end."

During an interview on 12/2/2023 at 12:02 p.m. with the Quality Manager (QM), QM stated everyone was a reporter when it came to abuse (intentional maltreatment of an individual that may cause physical or psychological injury). Staff should notify Adult Protective Service (APS- a government agency that assists adults when they are unable to meet their own needs, or are victims of abuse, neglect [failure to meet basic needs] or exploitation [deliberate maltreatment or manipulation]) as soon as possible and follow the step to notify charge nurse, department director and quality department. QM further stated the alleged abuser would be removed from the schedule during investigation.

During a review of the facility's policy and procedure (P&P) titled, "Abuse and Neglect," dated 10/2021, the P&P indicated, "[Name of facility] staff will notify the Department of all physical abuse or serious injury involving a psychiatric (mental, emotional and behavioral conditions) patient by appropriately transmitted document within 24 hours of occurrence."

During a review of the facility's policy and procedure (P&P) titled, "Mandated Adverse Event Reporting to the California Department of Public Health (agency responsible for investigation cases of reported abuse in healthcare facilities)," dated 6/2019, the P&P indicated, "It shall be the policy of the organization to report an adverse event (previously known as sentinel event), as defined by California Health and Safety Code §1279.1 (regulation that governs mandatory reporting)... to the California Department of Public Health (CDPH) no later than five days after the event has been detected ... An adverse event, as defined under the Code includes any of the following ... criminal events, including the following: the death of significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds." The P&P further indicated, "it will be the responsibility of the Quality Management Department to develop and submit the report to CDPH, as well as serve as liaison with CDPH during the subsequent investigation process."